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A 

SYNOPSIS 

OF THE 

VARIOUS KINDS 

OF 

DIFFICULT PARTURITION, 

WITH 
PRACTICAL REMARKS 

ON THE 

MANAGEMENT OF LABOURS. 

BY SAMUEL MERRIMAN, M. D. 

TEACHER OF MIBWIFERY; 

Physician -Accoucheur to the Middlesex Hospital, the Westminster 

General Dispensary, and the Parochial Infirmary of 

St. George, Hanover-Square. 

WITH NOTES AND ADDITIONS^ 

BY THOMAS C. JAMES, M. D. 

Professor of Midwifery in the University of Pennsylvania. 



«VW\A/WWW\<W\ 

Ha spatium tenuemque moram, male cuncta ministrat 
Impetus. Statu Theb. Lib. x, 

VW WWW WWW 



THE FIRST AMERICAN FROM THE SECOND LONDON EDITION 




PHILADELPHIA: \9>v ^cs** 

PUBLISHED BY THOMAS DOBSON, AT THE STONE HOUSE, 

NO. 41, SOUTH SECOND STB,EET. 

William Fry, Printer. 

1810. 






I 

of 






7?^7 



M$1 



District of Pennsylvania, to wit: 
******** BE IT REMEMBERED, that on the twenty- 
* SEAL. * nnitft day °f October, in the forty-first year of the 
% ' * independence of the United States of America, A. 

******** D. 1816, Thomas Dobson, of the said district, hath 
deposited in this office the title of a book the right whereof he 
claims as proprietor, in the words following", to wit: 

" A Synopsis of the various kinds of Difficult Parturition, with 
Practical Remarks on the Management of Labours. By Samuel 
Merriman, M. D. Teacher of Midwifery; Physician-Accoucheur 
to the Middlesex Hospital, the Westminster General Dispen- 
sary, and the Parochial Infirmary of St. George, Hanover- 
Square. With Notes and Additions, by Thomas C. James, M. 
D. Professor of Midwifery in the University of Pennsylvania. 
Da spatium tenuemque moram, male cuncta ministrat 
Impetus. Statu Theb. Lib. x. 

The first American from the second London edition. 

In conformity to the act of the Congress of the United States 9 
intituled, " An act for the encouragement of learning, by secu- 
ring the copies of maps, charts, and books, to the authors and 
proprietors of such copies, during the times therein mentioned." 
And also to the act, entitled, "An act supplementary to an act, 
entitled * An act for the encouragement of learning, by securing 
the copies of maps, charts, and books, to the authors and pro- 
prietors of such copies during the times therein mentioned,' and 
extending the benefits thereof to the arts of designing, engrav- 
ing, and etching historical and other prints." 

D.CALDWELL, 
Clerk of the District of Pennsylvania* 



ADVERTISEMENT. 

IT has sometimes appeared to the Editor of 
this Compendium, that a person could not be 
more usefully, although at the same time, per- 
haps, more humbly employed, than in bringing 
before the cultivators of medical science in the 
new world, those practical works that have ob- 
tained deserved celebrity in the old. The high 
price of European publications, as well as their 
rarity in this country, prevent their obtaining 
any thing like a general circulation among us; 
and like the manuscripts of the early ages, they 
are frequently only to be met with in the libra- 
ries of the rich, or the cabinets of the curious. 
Even, of the little work, of which he thus en- 
deavours to facilitate a more extended know- 
ledge, he has, as yet, met with but one copy in 
this country, and that imported by a specific 
order. He, nevertheless, believes it to be so 
worthy of the attention of the student and young 
practitioner of the art that it was written to 



IV 

illustrate and explain, that he did not hesitate, 
by the addition of some notes, tables, and an 
appendix, to add to it, any authority, however 
trivial, that such improvements may be sup- 
posed to confer. A few plates explanatory of 
the figure and dimensions of the pelvis, both in 
its perfect and deformed state, have been also 
added, to which a reference may be occasion- 
ally made, with some advantage, by the student, 
in the perusal of the work. 

One recommendation, suggested by the com- 
pendious and concise nature of the work, was 
that, from its size, it may, without inconve- 
nience, be made the companion of the young 
practitioner to the bedside of the patient; and 
may thus afford useful hints and supply neces- 
sary information, at the very period when they 
may be most wanted by the attentive, although 
perhaps, inexperienced assistant of the opera- 
tions of nature. 

Philadelphia, Oct. 25, 1816. 



THE 



AUTHOR'S PREFACE. 



l\\V\AW\\V% 



ABOUT a year ago, I drew up, in a nosologi- 
cal form, a list of the various kinds of difficult 
labours, most commonly met with in practice. 
I was induced to do this, that I might be ena- 
bled to describe each kind more precisely in my 
Lectures; and I published the arrangement in a 
small pamphlet, for the use of those gentlemen 
who attended my Courses. 

Finding, however, that the book was often 
asked for, and sold at the booksellers, and being 
about to publish a new edition, I was desirous 
of endeavouring to render it somewhat more 
useful, by adding such remarks upon the ma- 
nagement of labours, as a pretty extensive 
practice in midwifery had taught me to approve. 



VI 

But I have attempted nothing more than to 
give a sketch of obstetrical practice, to form 
such a Compendium of Midwifery as might 
occasionally supply the place of a more volumi- 
nous work, in suggesting a hint or a caution, or 
in recalling to the mind an observation useful to 
the young practitioner. Thus this little book 
may serve the purpose of a Vade-Mecum, but 
will not supersede the perusal and study of more 
elaborate systems of midwifery. 

At the end I have inserted tables of accidents, 
unusual presentations, deaths, Sec. in labour and 
childbed. The first is collected from 1800 
women, in my own practice; the third is taken 
from Dr. Bland's Calculations; the second and 
fourth are from French authors; and the fifth, 
taken from the London Bills of Mortality, de- 
monstrates how many more lives were formerly 
lost in child-bed, than are met with in modem 
practice. 

Oct. 13, 1814. \ 



CONTENTS. 



•WWW-VVXWV 



Class I. Eutocia simplex, or Natural Labour . 9 
Class 2. Dystocia, or Difficult Labour . . 27 
Order 1. Dystocia Diutina, or Lingering Labour . ib. 

2. Dystocia Anenergica, or Powerless Labour 49 

3. Dystocia Perversa, or Malfiosition of Head 54 

4. Dystocia Amorfihica, or Deformity of 

Pelvis 64 

Signs of a Dead Child . . . .66 

5. Dystocia Obturatoria, or Obstruction in 

the Soft Parts .... 72 

6. Dystocia Ectofiica, or Displacement of 

the Uterus 77 

7. Dystocia Transversa, or Preternatural 

Presentations . . . • 81 

a. Nates . 86 

b. Inferior Extremities . . . 93 

c. Superior Extremities . . .104 

d. Back, Belly, and Sides . . . 119 

e. Navel String 121 



VU'l CONTENTS. 

Page 

Order 8. Dystocia Gemina, or Twin Children . 130 

9. Dystocia Laceratoria, Ruptures or 

Lacerations . . . . 143 

10. Dystocia Hemorrhagica^ or Hemorrha- 

ges 159 

11. Dystocia Syncopalis, or Paintings and 

Palpitations . . . . 179 

12. Dystocia Convulsiva, or Convulsions . 183 

13. Dystocia Infafmnatoria, Inflammation 

or Fever 198 

14. Dystocia Retentiva, or Retention of the 

Placenta 201 

15. Dystocia Inversoria, or Inversion of the 

Uterus 212 

Of the Use of Instruments in Midwifery . .213 

Of the Fillet y Forceps, and Vectis . . . 218 

Of the Perforator 229 

Of the Cesarean Operation . . . . 239 

Of inducing Prematura Labour .... 242 

Tables 247 

Appendix . . . » . • • .261 

Plates and Explanations . . . . 289 



LABOURS 

MAY BE DIVIDED INTO 

TWO CLASSES: 

* 1 . Eutocia — Natural L abour. 
t 2. Dystoci a — Difficult Labour. 



CLASS I.— EUTOCIA, 

COMPREHENDS ONLY ONE ORDER. 

I. Eutocia Simplex — Natural Labour.. 



Natural Labour. Smellie, Denman, Plenck, 8cc. 
Easy Labour. Cooper. 



Definition. — Natural labour is that, in which 
the vertex presents, the head descends 

♦From E«, bene, and tik\u, pario, seu tokos, partus. 
t From 2vs, difficulter, and tokos, partus. 

B 



10 

readily into the pelvis, taking such a direc- 
tion as brings the occiput to emerge under 
the arch of the pubes. The labour termi- 
nates within twenty- four hours after its 
commencement. The placenta is expelled 
within one hour after the birth of the child. 
The whole process is passed through with- 
out danger to the mother. 

#£# Mr. Burns considers it as essential 
to natural labour that it shall not occur 
before the full term of nine months; he has 
therefore in his classification of labours, 
introduced premature labour ', as his second 
class. 

Mauriceau considered it not only essen- 
tial that the woman should have reached 
the full term of pregnancy, but likewise 
that the child should be born alive, in order 
to constitute natural labour.* 



* " Quatre conditions se doivent absolument rencontrer 
en I'accouchement pour pouvoir etre veritablement dit 



11 



Of the different Stages of Labour. 

Labour is divided into four stages or periods. 

1. During the first stage, the head of the fetus 
passes through the superior aperture of the pel- 
vis, and the os uteri becomes dilated at least to 
the size of a crown piece. [This may therefore 
be termed the entrance of the head into the 
pelvis.] 

2. The second stage produces that change in 
the position of the head, which turns the fore- 
head into the hollow of the sacrum, and brings 
the occiput to emerge under the arch of the 
pubes. [This may be termed the passage of the 
head through the pelvis.] 

3. The third stage produces the expulsion of 
the child through the os externum. 



naturel: 1, qu'il arrive a terme; 2, qu'il soit prompt, et 
sans aucuns accidents considerables; 3, que Venfant soit 
vivxintj 4, qu'il vienne en bonne figure et situation. 

Mauriceau, torn. 1. p. 202. 



12 

4. The fourth stage is accomplished by the 
delivery of the placenta.* 

*£* Sometimes the os uteri becomes 
completely dilated during the first stage: at 
other times this is not accomplished till the 
second stage is nearly over. 

J* J The time at which the membranes 
rupture is very various. The longer they 
remain entire, the safer in general is the 
labour. That labour is the most truly na- 
tural, in which the liquor amnii (popularly 
called the waters) is not evacuated till the 



* Dr. Denman divides labour into three stages only. 
# The first includes the dilatation of the os uteri: the 
rupture of the membrane: the discharge of the waters. 
The second, the descent of the child: the dilatation of 
the external parts: the expulsion of the child. The third, 
the separation of the placenta: the expulsion or extrac- 
tion of the placenta." 

Denman? 8 Aphorisms, p. 3. 

Mr. Hogben divides labour into five stages. The first 
lasts from the commencement of labour till the child's 



13 

head of the child is just ready to pass into 
the world.* 

Of the precursory Symptoms of Labour. 

Labour is usually preceded by 

1. A general and equal subsidence of the 
uterus and abdomen. 



head enters the brim of the pelvis. The second, is the 
time in which the face is passing into the lower pelvis, 
the face turning into the cavity of the sacrum. The 
third, the further advance of the head without the os 
externum. The fourth, the expulsion of the body and 
lower extremities of the child. The fifth, the discharge 
of the placenta and membranes. 

Ifogbcn's Obstetric Studies, p. 33. 

Dr. Romer of Zurich, makes four stages of labour. 
The first is known by the precursory pains: dolores 
prasagientes: the second by the preparatory pains: 
dolores prapar antes: the third by the true pains: dolores 
veriad partum: the fourth by the vehement forcing pains: 
dolores conquassantes. 

Homer Partus naturalis brevis Expositio. 

Got ting os, 1786. 

* « In easy natural labour, the waters are all along 
protruded before the child's head, in a regular forms 



14 

This is a favourable symptom, as 
it indicates that the pelvis is well 
formed, and that the parts are pro- 
perly disposed for labour. 
2. A discharge of a glairy or mucous fluid 
from the vagina. 

When this discharge is tinged with 
blood it is popularly called a shew; 
but this appearance is frequently not 
perceived till the labour has made 
considerable progress. 



and the membranes do not break till they have dilated 
the os externum; by which time the head of the child is 
advanced pretty low in the pelvis, and the membranes 
being then stretched to their utmost degree of disten- 
sion, are burst in the time of a pain, by the force of the 
protruding waters; on which the child's head immediate- 
ly falls to the edge of the os externum, and in another 
pain or two, the occiput rises round the edge of the 
pubes, and a very trifling assistance brings it into the 
world; and indeed it seldom requires any, the same pain 
that breaks the membranes, being frequently sufficient 
to protrude the child also." 

Coofier's Compendium of Midwifery, 1766, fi. 87. 



15 

3. Frequent gripings or tenesmus. 

4. A frequent urgency to make water. 

Occurrences during Labour. 

Pains. Rigors. 

Restlessness. Vomitings. 

Despondency. Profuse perspirations. 

Pains are of two kinds, spurious and true. 

Spurious pains are to be distinguished 
by their irregular recurrence; 
by affecting the belly more than the back 

or sides; 
by not producing any dilatation of the os 
uteri. 

Spurious pains are to be relieved, 

by aperients, if arising from costiveness or 
indigestion; 

by absorbents, if from superabundant aci- 
dity in the intestines; 

by opiates, if from spasm or fatigue; 

by bleeding, if from inflammation or fever. 



16 

True pains may be known 

by their recurring at regular intervals; 

by affecting the back and shooting round to 
the thighs; 

by producing a sensible opening or dilata- 
tion of the os uteri during each pain; 

by protruding the membranes, like a blad- 
der filled with water, through the os 
uteri. 

True pains are of two kinds, 

1. Grinding \ rending, cutting pains,* 
when the os uteri first begins to open. 

2. Bearing or forcing pains, f after the os 
internum is somewhat opened, and the 
bag of waters, or the head of the child, 
is forced through the circular mouth of 
the womb, producing its more complete 



*Or the pains of Dilatation, 
t Or the pains of Expulsion. 



11 

dilatation, and afterwards expelling 
child through the os externum. 

The restlessness and despondency which par- 
turient women experience, most commonly 
occur in the early stages, and are produced by 
nervous irritability during the continuance of 
the grinding pains: these symptoms are generally 
removed or relieved when the bearing pains 
come on.* 

Rigors or tkritimgs often happen during the 
dilatation of the os uteri; sometimes they ac- 
company every pain; more frequently they pre- 
vail most, when the os uteri first begins to 
dilate, and at the time when the dilatation is 
about to be folly accomplished. Not uncom- 



•G : . -. :t : -.:-:::.; = ; i-. :'. ;i :-..:: i -.:;.-. sir. t:_rir5 :•::_. 
;:. :.::;:- _:.; _. •■■;.;-. :'r.e ~i'.:t7.. 'i i::er. :-... :e:;r:\es 
nearbr or quite exhausted, and are then to be looked 

c 



18 

monly they precede the passage of the head 
through the os externum, and terminate by 
producing a violent cramp in the lower extre- 
mities. 

Rigors or thrillings are generally esteemed 
favourable indications of labour; but they should 
be distinguished from those severe, distinct 
shivering fits which are the forerunners of fever, 
and consequently productive of danger.* 

It is frequently useful to give warm diluting 
drinks during these rigors, such as tea, thin 
gruel, weak broths, &c; but the custom of 
giving spiced caudle, warm beer, mulled wines, 
or spirits and water, is highly reprehensible, 
though very common among the lower ranks 
of society. 



* Shivering fits, the forerunners of fever, more com- 
monly happen in long and difficult, than in natural 
labours. 



19 

Vomiting is likewise looked upon as a veij 
favourable occurrence during labour, agreeably 
to an old adage often quoted in the lying-in 
chamber, " that sick labours are safe ones:' ? 
and inasmuch as it removes from the stomach 
improper food or drink, which are often, particu- 
larly among the lower ranks, the exciting causes 
of this symptom, it is beneficial. 

Vomiting is likewise sometimes useful by 
producing relaxation; thus it is often observed, 
that pains accompanied with vomiting occasion 
a greater and more rapid dilatation of the os 
uteri, than would be produced by the pains 
alone, without the vomiting. 

But vomiting ought to create alarm, 

if it occurs after a long continuance of 

labour, 
if the os uteri is completely dilated, 
if the pains are suspended, or have alto- 
gether ceased, 



20 

if the patient is feverish, 
if the fluid ejected be of a dingy, san- 
guineous, or blackish hue. 

Perspiration is a natural consequence of la- 
bour; but the degree of it depends upon various 
causes and peculiar constitutions. The relaxa- 
tion that natural perspiration produces in the 
system, doubtless tends to facilitate parturition; 
but artificial perspiration brought on by loading 
the patient with too many bed-clothes; by keep- 
ing the lying-in chamber too hot and close; or 
by giving heating liquors, exhausts the strength, 
and tends in every instance to delay the progress 
of the labour. 

Rules for the Management of Xatural Labour. 

1. Natural labour requires but little assistance 
on the part of the accoucheur. He must 
recollect that the dilatation of the soft parts 
will be effected by the natural pains, assisted 
by the bag of waters gradually insinuating 



21 

itself through the os uteri and vagina, 
much more easily and more safely, than by 
any artificial means that he can employ; of 
course no attempts ought to be made by 
him to produce artificial dilatation. 

2. During the first and second stages, the pa- 
tient may be allowed to sit, stand, kneel, 
or walk about, as her inclination may 
prompt her; if fatigued she should repose 
occasionally upon the bed or a couch, but 
it is not expedient during these two stages 
that she should remain very long at a time 
in a recumbent posture. 

3. She should be supplied from time to time 
with mild bland nourishment in moderate 
quantities. Tea, coffee, gruel, barley water, 
milk and water, broths, &c. may safely be 
allowed. Beer, wine, or spirits, undiluted 
or diluted, should be forbidden: they are 
very rarely required even when the third 



22 

stage of labour is nearly terminated, but in 
the earlier periods, are almost always mani- 
festly injurious. 

The attendants in the lying-in chamber fre- 
quently object to toast and water, lemonade, 
oranges, and other subacid fruits, &c. but under 
many circumstances such articles are highly 
grateful to the patient, and may be indulged in 
without hazard. 

4. Frequent opportunities should be afforded 
the patient of passing her water. * 

5. If costive, the bowels should be opened by 
castor oil or other mild aperient, or by 
clysters. 

6. It will be necessary for the practitioner 
to pass his finger occasionally per vaginam i 

* By the occasional absence of the practitioner. 



23 

in order to judge of the progress of the 
labour: but this should not be too often 
repeated, and great care must be taken not 
to rupture the membranes. 

7. The spirits of the patient should be kept 
up by kind and cheerful conversation. 
All noisy discourse, all conversation on 
melancholy or unpleasant topics, should be 
checked. Particularly no mention should 
be made of unfortunate cases in mid- 
wifery. Reflections on the conduct and 
behaviour of other practitioners should be 
discouraged. 

8. Towards the end of the second stage of 
labour the patient should be placed upon 
the bed properly made up and secured; 
and in the third stage, as soon as the head 
of the child begins to protrude through the 
os externum, the accoucheur should place 
his hand covered by a soft napkin in such 



24 

a manner as shall support the perinasum 
and guard it from laceration. 

9. After the head has passed, it is best to 
wait for another pain or two to expel the 
shoulders, and not hastily to drag them into 
the world. 

10. After the child has breathed freely and 
cried vigorously, a ligature may be made 
upon the navel string at a distance of one 
or two inches from the belly, and another 
an inch nearer to the placenta, and the 
funis should be divided with a pair of 
scissors between the two ligatures. This 
operation should never be performed under 
the bed-clothes. A surgeon-accoucheur 
not long since included one of the little 
fingers of the child in the ligature which 
he had made upon the funis, and cut off 
the first joint with his scissors. This acci- 



25 

dent could not have happened had he 
brought the part to be divided into view. 

11. After the child is born, secondary pains 
come on to separate the placenta; these 
usually occur in less than twenty minutes, 
and the placenta is thrown by them into the 
vagina, from whence it is easily extracted 
by the accoucheur. 

12. Before the practitioner quits his patient 
he should 

1. lay his hand upon the abdomen, to satis- 
fy himself that the whole contents of the 
uterus are expelled; 

2. feel her pulse, that he may not leave her 
in a state of faintness; 

3. examine that the funis of the child is 
properly secured. 

Labours of the class Eutccia do not often 
last so long as twenty -four hours, especially if 



26 

the woman has already borne a child. Of the 
last 200 women that I have attended in natural 
labour, 



64 were delivered within 6 hours: here were no first children. 

76 ', 12 hours: among these were 11 first labours. 

46 18 hours: among these were 14 do. 

14 24 hours: among these were 7 do. 

200 32 



*#* Should any circumstances arise during 
the process of parturition that make it 
more painful, slower, or more difficult than 
ordinary; that place the mother's life in 
danger; or that render artificial assistance 
necessary; such labour must be reckoned 
as belonging to the class DYSTOCIA. 



27 



CLASS II.— DYSTOCIA. 



COMPREHENDS FIFTEEN ORDERS, 



Order 1. Dystocia Diutina — Lingering Labour. 



Natural Labour, No. 3. Lingering Labour. Smel- 

lie. 
Slow and Painful Labour. Watts. 
Lingering and Perplexing Labour. Cooper. 
Tedious Labour. Burns, Class IV. 
Difficult (but Natural) Labour. Hogben. 
Dystocia Protracta. Young's Nosology, CI. V. 

Order 17, $ 6. 



Definition. — Labour in which the head presents 
as in Eutocia; which terminates without 
danger to the mother; which is effected 
principally by the natural pains; but which 
occupies a space of time exceeding twenty. 
four hours. 



28 

Dystocia Diutina, is usually attributable to one 
or more of the following causes. 

a. original or accidental weakness of habit 
in the mother, producing inert, or irre- 
gular or partial action of the uterus. 

Dystocia a Debilitate. Sauvages, 

O. 22, § 1. 
Tedious Labour. Order 1. Burns. 

b. a rigid and undilateable state of the os 

uteri, and other parts concerned in the 

process of parturition. 

Dyst. ab Angustid. Sauvages, § 4. 
Tedious Labour. Order 2. Burns. 

c. small size of the pelvis, or a very slight 
degree of distortion. 

D. ab Angustid. Sauvages. 

d. the size of the fetus being unusually 
large, or the bones of the head not easily 
compressible. 



29 



e. monstrous formation of the fetus. 

D. a Mole Foetus. Sauvages, § 5. 
Laborious labour from increased 
bulk of the infant. Hamilton - 



f. extreme distention of the uterus, from 
an excessive quantity of the liquor 
amnii. 

g. extraordinary thickness of the mem- 
branes (chorion and amnion.) 

h. too early an evacuation of the liquor 
amnii. 

i. sudden and violent affections of the 
mind. 

D. a. Pathemate. Sauvages, § 3. 

k. the fetus being dead. 

D. a Fcetu mortuo. Sauvages, § 6, 

1. The funis umbilicalis being naturally too 



30 

short, or accidentally shortened by being 
twisted round the child. 

The method of managing women in lingering 
labour must in a great measure depend upon 
the cause of the difficulty. 

1. In treating difficult labours arising from 
the first cause enumerated (a), it will be neces- 
sary to allow a great deal of time for the parts 
to develope themselves. The patient's strength 
must be supported; and this will be best effect- 
ed by mild nourishment, as gruel, arrow root, 
panada, chocolate or cocoa, beef tea, veal broth, 
&c. If the pulse requires it, add a little wine. 

Open the bowels by clysters. Avoid fatiguing 
the patient. Be careful not to keep her too hot, 
or much oppressed by the weight of the bed- 
clothes. — Change her posture occasionally. — 
Encourage her by a cheerful unembarrassed 
manner. Promise a safe delivery, but avoid 



31 

fixing any period for the duration of the 
labour. 

Medicine does not seem capable of doing 
much good, in such cases: yet sometimes it 
may be expedient to amuse the patient by 
giving a few drops of liq. vol. corn, cervi, — 
spir, ammon. comp. — spir. Athens sulphur — 
or sp. lavend. comp, in camphor julep, or 
aq. menth. virid. 

If there be a want of rest, from «ix to mxx* 
of tinct. opii. may be given with great advan- 
tage. Much larger doses of opium, namely to 
the extent of 6, 8, 10 grains of extr. opii. have 
been recommended in this kind of slow labour 
with a view to relax spasm, and render the 
uterine action more perfect; f but such hercu- 



* Minims, or drops. 

t From repeated trials of the effects of the Secalc 
Cornuturri) or Spurred Rye, the editor does not hesitate 



32 

lean doses can very rarely be necessary, and 
would not always be safe. 

2. In labours of the next kind (b) our great 
resource is to allow time. The grinding pains 
will frequently last for 12, 18, 24, and 36 hours: 
while these continue, speak of them as only 
preparatory pains, not as the real pains of 
labour. 

If the teasing irksomeness of the pains pre- 
vents the patient from getting rest, give at 
discretion a dose of laudanum. 



to confirm the report of Drs. Stearns and Prescott, that 
in these cases it may be exhibited with great advantage 
after a sufficient dilatation of the soft parts concerned in 
parturition has taken place. To render the uterine 
action more perfect therefore, it may be given in the 
dose of 9j. finely powdered, and suspended in a little 
molasses and water — and this dose may even be repeat- 
ed, should it fail in rendering the contractions of the 
uterus energetic in the course of half an hour — but the 
editor has never found it necessary to exhibit a third 
dose. — Ed. 



33 

Let the patient keep pretty much in an erect 
posture, but be careful not to overfatigue her. 
Avoid whatever is likely to produce fever. Let 
her diet be spare and simple. Her drink should 
be tea, or toast and water, or milk and water, 
or barley water. Avoid cordials and stimulants. 

Pay great attention to the state of the blad- 
der, that it may not become over distended. 

Open the bowels by clysters, or by castor 
oil, or by salts dissolved in emulsion or gruel.* 



* In cases of lingering labour, especially if the pains 
had become suspended, Mauriceau was partial to the 
practice of giving an infusion of two drachms of senna 
in a small quantity of water, acidulated with the juice of 
a Seville orange: after this had been taken about two 
hours, he threw up a stimulating clyster. And from the 
combined effect of these remedies he frequently experi- 
enced great advantage. It has been thought that the 
griping quality of the senna and orange juice, was the 
cause of stimulating the uterus to fresh exertions by 



34 

Fomentations to the abdomen have been re- 
commended; but I have not experienced any 
marked advantage from them. Sitting over the 
steam of warm water is sometimes beneficial. 

Some practitioners are fond of introducing 
lard or pomatum in order to induce relaxation; 
but this never does good unless the rigidity is 
confined to the vagina or external parts; it may 
then be frequently used with advantage. 

Gardien and other French accoucheurs, in- 
ject mucilaginous liquids, (as injus. althcea vel 
lint) into the vagina; and where there is a want 
of the natural mucus, and much heat and sore- 



sympathy with the bowels. I have several times tried 
Mauriceau's remedy with good effect; but a solution of 
salts or castor oil are, according to my experience, 
equally useful. The practice of giving aperients by the 
mouth, is often of use during labour, especially in 
women habitually costive. 



35 

ness in the parts, this may probably be a useful 
practice. Rueff, who published in 1554, recom- 
mends to introduce a composition of oil and the 
whites of eggs. 

In cases of great rigidity, particularly if there 
be any tendency to inflammation, the abstraction 
of blood is frequently beneficial. This practice 
has been carried to a great extent in America, 
where women have been bled to the amount of 
20, 30, 40, 50 or more ounces at a time, for 
the purpose of producing general relaxation, and 
consequently a more speedy dilatation of the os 
uteri and the external organs. But it may be 
doubted whether patients in general would 
recover w r ell after so great a loss of blood. 

An accoucheur at Paris lately professed to 
teach a secret, by which all women, even the 
most deformed, might be easily delivered. His 
method was to give an emetic to the parturient 
woman, and he expected that the violent strain- 



36 

ing to vomit would greatly contribute to force 
the infant through the pelvis. It was soon found 
that this method was altogether inefficacious in 
cases of distortion; he was therefore compelled 
to restrict the practice to cases of slow labour, 
where the pelvis was well formed; but even in 
these cases, this plan does not seem to have 
been productive of much advantage,* and is, I 
believe, at present, seldom employed. 

Upon the principle of producing relaxation, 
the use of the warm bath has been recommend- 
ed. This was tried by Dr. Smith in America, 
but excessive haemorrhage was so often found 
to be the consequence, that this practice was 
abandoned. Gardien considers that this acci- 
dent might be prevented, by having recourse 



* See Gardien Traite d'AccouchemenS) torn. ii. p. 273 
—1807. 



37 

to bleeding before the bath was used; but he 
does not appear to speak experimentally. 

Upon the same principle of inducing relax- 
ation and consequent dilatation of the os uteri, 
clysters of tobacco were recommended in Ame- 
rica, but the alarming symptoms which followed 
in the single case where tobacco was thus em- 
ployed, will, I trust, prevent a repetition of this 
experiment.* 

3. The treatment of dystocia dintina arising 
from either of the causes marked (c) (d) (e) 
must be nearly the same. Much must be trust- 
ed to time. If care be taken to avoid all causes 
of fever and inflammation, and to prevent the 



* See M An Essay on the Means of lessening Pain, and 
facilitating' certain Cases of difficult Parturition. By TV. 
P. Dewees, M. Z>." 1806, And the Medical and Physical 
Journal, vol. xviii. 



38 

patient from exhausting her strength by unavail- 
ing strainings, the labour may be suffered to 
proceed for very many hours without danger; 
and at length the head of the fetus may be 
squeezed through the pelvis, very much elon- 
gated and compressed: yet the child may be 
born living, and the mother may have a favour- 
able recovery. 

4. Dystocia diutina has very often been as- 
cribed to one or other of the causes marked 
(f) and (g), but frequently without sufficient 
reason. 

When an excessive quantity of the liquor 
amnii, or an extreme thickness of the mem- 
branes is really the cause of a slow labour, the 
obvious remedy is to rupture the membranes: 
but this requires very great caution; for if rup- 
turing the membranes does not produce manifest 
advantage, it almost always occasions great in- 
convenience, increases the distress of the patient, 



39 

and not uncommonly places her or the child in 
a state of danger. 

It may be safely laid down as a rule, (which 
will admit of very few exceptions) that the 
membranes should not be artificially ruptured, 

1. while the head of the fetus, or a large 
portion of it, is above the brim of the 
pelvis. 

2. while the os uteri is undilated, or in a 
state of rigidity. 

3. while the perinaeum is thick and firm, 
or rigid. 

These rules are especially to be observed, if 
the woman is in labour of her first child. 

5. The membranes sometimes rupture spon- 
taneously (h) without previous notice, or any 



40 

explicable cause. When this happens, the 
waters usually escape from the uterus, in small 
quantities at a time, keeping the woman con- 
stantly wet and uncomfortable. This is called 
the dribbling of the waters: and no uterine 
action comes on till nearly the whole of the 
liquor amnii is discharged; so that frequently 
24, 48, or more hours elapse, before any true 
labour pains are felt. When labour actually 
takes place, it often terminates as safely as if 
this accident had not happened: but commonly 
the pains are more severe and cutting. 

Very little can be done on the part of the 
practitioner, except observing the rules, thai are 
applicable to the case of rigidity of the soft parts 
(b). It is right to examine per vaginam early 
after the waters have begun to drain away, in 
order that he may be satisfied whether the fetus 
presents properly: if not, the patient should be 
frequently visited, and a strict injunction should 
be given to the attendants to send for the 



41 

accoucheur, as soon as the pains of labour 
commence. 

It has been proposed to introduce a finger 
within the os uteri, and lift up the head of the 
child, so as to allow a more expeditious dis- 
charge of the waters: but this could not often 
prove beneficial. 

6. Practitioners of all ages have agreed that 
the action of the uterus is very much influenced 
by the mental powers (i). Evidences of this 
are to be found in many medical records; and 
the fact is presented to our view in many oc- 
currences of common life. It is therefore to be 
considered of importance, that the mind of the 
parturient woman should be kept as easy and 
tranquil as possible. 

7. The death of the fetus (k) is not necessa- 
rily a cause of lingering labour. The affection 
of the mother, of whatever nature it might be, 

F 



42 

which occasioned the death of the child, may 
possibly retard the labour, otherwise it will ter- 
minate favourably, unless the size of the fetus is 
increased by putrefaction.* 

8. Shortness of the navel string (1) will sel- 
dom be a cause of lingering labour, till the head 
is about to pass through the external parts: it 
may then be an impediment to the birth by 
occasioning the head to be retracted after each 
pain. 

We are not however always to conclude, 
that the retraction of the head is produced by 
shortness of the funis; for the resilition of the 



* " When a child after death becomes putrid, and 
thence enormously swelled by the included and rarefied 
air, the birth will be impeded, but the difficulty will 
arise not from the death of the child, but from its in- 
creased bulk." 

Bland's Description of the Lever. 



43 

parts, especially in first labours, occasions a 
greater or less degree of retraction of the head. 

The delay in the labour which shortness of 
the funis occasions, is generally soon overcome. 
Changing the position of the woman sometimes 
facilitates the birth. 

It has been recommended, after the head is 
born, if the birth of the shoulders is prevented, 
by the navel string being twisted round the 
neck of the child, to introduce a pair of scissors, 
divide the funis, and thus set the parts at liberty. 
This operation may sometimes be expedient; 
great care being taken to guard against doing 
mischief: but it is proper to remark that Dr. 
Denman relates a case of the death of the infant 
from dividing the funis under these circum- 
stances.* 



Introduction to Midwifery^ p, 288, 4to. edit. 



44 

Besides the causes of difficult parturition 
above enumerated, it sometimes happens that 
incautious practitioners occasion lingering la- 
bours, by mismanaging the different stages, 
and thus interrupting the natural progress of 
the labour: and this may be effected, 

by the injurious practice of giving cordials 
and strong drinks, under a false idea of 
supporting the patient's strength; 

by keeping the room too hot and close; 

by letting the patient remain too long in 
bed; 

by allowing too much company, who fatigue 
the patient by their noise and talking; 

by urging the woman to exert herself in 
bearing down before the parts are well 
dilated; 

by injudicious and unavailing attempts to 
give assistance; 

by prematurely rupturing the membranes; 



45 

by suffering the bladder to become over 
distended;* 

by not timely opening the bowels. 

Whenever from any such cause the progress 
of the labour is impeded or suspended, it 
becomes the practitioner to retrace his steps, 
and endeavour to place his patient in the same 
state that she would have been in, had he not 
indiscreetly admitted of such injurious practice. 
The rules already laid down for the treatment 
of dystocia diutina, when occurring from natu- 
ral causes, will be applicable to the cases, which 
are rendered difficult by artificial causes. 

Instances of dystocia diutina, including first 
and all other labours, probably occur as often 
as once in 30 cases: but it is very difficult to 



* This forms " Complicated Labour." Class 7. Order 
6. Burns, 



46 

form an exact average. They are much more 
common with first children than with others.* 

From what has been remarked respecting this 
order of labours, it is apparent: 



* Among the last 120 women that I have attended in 
their first labours-— 

95 were cases of eutocia; 

56 being delivered within 12 hours. 

39 in between 12 and 24 hours. 

£5 were cases of dystocia diutina. 

9 were delivered in between 24 and 30 hours. 

9 30 and 40 

2 40 and 50 

2 50 and 60 

2 60 and 70 

1 70 and 80 

All the above women recovered perfectly from the 
state of child-bed, and two only of the children lost their 
lives during the labour. In one of the cases where the 
child died, the mother was only 20 hours in labour: in 
the other case, the woman was 68 hours in labour. 

Six others of the children were dead born, but had 
evidently been dead several days before the labours 
came on. 



47 

that many causes may produce dystocia 
diutina; 

that in all such cases much delay must 
necessarily take place; 

that frequently very little progress will be 
made, though the labour may have lasted 
for several hours; 

that sometimes many days will elapse be- 
fore the termination of the labour; yet it 
may at length terminate safely both to 
the mother and the child, without arti- 
ficial assistance.* 



* Mr. Burns, in his " Principles of Midwifery/' first 
edit. p. 242, quotes from Dr. Breen's Tables of Labours 
at the Dublin Lying-in Hospital: 

172 cases of slow labour in women with their first children. 
91 in women m ho had formerly borne children. 

In the first class 34 were from 30 to 40 hours in labour. 

103 40 .. 50 do. 

24 70 . . 80 do. 

12 90 . l(>0 do. 

And 121 of the children were born alive. 

In 



48 

It must however be remembered, that all 
women are not equally capable of undergoing 
such long continued sufferings as sometimes 
occur in this order of labours. Occasionally it 
will be found, that cases of dystocia diutina will 
be so long protracted as to bring the patient into 
a state of exhaustion which deprives her of the 
power of further exertion: when this happens 
the case no longer belongs to the order dystocia 
diutina> but comes under the next order. 



In the second class 28 were from 30 to 40 hours in labour. 

48 40 . . 50 do. 

6 50 . . 60 do. 

9 70 . . 80 do. 

And 66 of the children were born alive. 

No mention is made of any death among the women, 
it may be presumed therefore that they all recovered. 



49 



Order 2. Dystocia Anenergica — Powerless 
Labour. 



Difficult and Perilous Labour. Cooper. 
Laborious Labour. Order 2. Hamilton. 
Laborious, or Instrumental Labour. Burns. 



Definition. — Labour of long but indefinite con- 
tinuance, in which the pains becoming 
weak and inefficacious, or being entirely- 
suspended, and the patient exhausted by 
her sufferings, it becomes necessary to 
afford artificial assistance to terminate the 
labour. 

D. Diutina and D. Anenergica may be distin- 
guished from each other by the following 
symptoms: 

c 



so 

Favourable Symptoms constituting Dystocia 
Diutina. 

1. A regular recurrence of uterine action. 

2. Perceptible progress in the labour, how- 
ever slow. 

3. The patient's strength being unim- 
paired. 

4. Her mind being tranquil. 

5. A disposition to quiet sleep in the in- 
tervals of her pains. 

6. The absence of fever or inflammation. 

7. The vagina and os uteri feeling cool and 
moist. 

8. The patient possessing the power of 
voiding her urine. 

While these symptoms are present, the labour 
may be safely trusted to nature. 

Unfavourable Symptoms indicating Dystocia 
Anenergica. 
1. Severe shivering fits unconnected with 



51 

dilatation of the os uteri, or of the 
passage of the head through the os 
externum. — See p. 18. 

2. Frequent or constant vomitings after the 
os uteri is dilated. 

3. The accession of fever. 

4. Great restlessness or jactitation. 

5. A disturbed and anxious mind. 

6. The want of true uterine action, though 
there may be irregular and unproductive 
pains, and this happening after many 
hours of labour.* 



. * Here the use of the Secale Cornutum, or Spurred 
Rye, has been often resorted to by the editor, with the 
happiest effects. He has been for some time past, in 
the habit of giving it in these cases, after the soft parts 
have been sufficiently dilated, in the dose of £j. finely 
powdered (as mentioned in a preceding note) and sus- 
pended in molasses and water. 

Its effects in increasing the uterine contractions are 
generally observable within half an hour; and he has 
seldom found it necessary to repeat the dose. A second 



52 

7. Heat and soreness in the vagina and 
os uteri. 

8. Offensive discharges from the uterus. 

9. Violent and continual pain and soreness, 
or tenderness of the belly. 

10. Low muttering delirium. 

11. A quick and weak, or low sinking 
pulse. 

12. Clammy sweats. 

In proportion to the number and severity of 
these symptoms will be the danger of the 



scruple has been sometimes exhibited at the interval of 
half an hour, but he has never gone beyond this. Given 
to this extent, he has never witnessed any unpleasant 
consequences resulting either to mother or child — and 
he believes that in cautious and prudent hands, it may, in 
certain cases, obviate the necessity of having recourse 
to the application of instruments, generally so abhor- 
rent to female delicacy, as well as irksome and unplea- 
sant to the practitioner.— Ed. 



53 

patient, and unless artificial aid be timely afford- 
ed, both mother and child will perish. 

The assistance to be afforded will generally 
be that of the forceps or vectis; for, unless in 
cases of distorted pelvis, the head of the fetus 
will have sunk low enough to allow the ear to 
be felt, before the strength of the patient 
becomes quite exhausted. 



54 



Order 3. Dystocia Perversa — Labour, the 
Head presenting in a wrong Direction. 



Natural- Labour, No. 2. Smellie. 
Variety of Natural Labour. Denman. 
Preternatural Labour. Class 3. Order 5. Burns, 



The French writers on midwifery enumerate 
more than twenty kinds of malposition of the 
head, but it is sufficient for all useful purposes 
to resolve them into three: 

a. The forehead turned towards the pubes. 

b. the face presenting. 

c. the position of the head altered, by the 
descent of the hand or arm with the head 
into the pelvis. 



55 

1. The most common of all the wrong pre- 
sentations of the head, is that of the forehead 
towards the pubes (a), divided by M. Gardien 
into three species: — 

Position fronto-cotylo'idienne gauche.* 

fronto cotyloidienne droit e.\ 

frontO'pubienne.% 

Tuaite d'Accouchemens, torn. ii. p. 307. 

This kind of presentation is seldom discover- 
ed at the first examination. The accoucheur 
having ascertained that the head is the present- 
ing part, feels little solicitude about its exact 
position. The labour, however, being much 
more severe, or continuing longer than he had 
expected, because in this position the bones of 
the fetal head do not readily adapt themselves 



• Or the anterior fontanelle to the left acetabulum, 
t Or the ant. fontanelle to the right acetabulum. 
\ Or the ant. font, to the symphysis pubis. 



56 

to the shape of the pelvis, he is induced to make 
a more accurate examination, and then discovers 
the wrong position by the following indica- 
tions: — 

The presenting part is not so conical to. 

wards the arch of the pubes. 
The bones do not ride one over the other. 

The scalp does not form into a cushion. 

The hollow of the sacrum is not so com- 
pletely filled up by the head. 

The anterior fontanelle is to be felt towards 
the symphysis pubis.* 



* The anterior fontanelle in these presentations, is 
readily distinguished by its four angles, and a suture 
proceeding from each angle — the posterior fontanelle 
having but three angles, and a suture proceeding from 
each angle. 

If the anterior fontanelle is readily felt upon an 
examination per vaginam, we may expect that the head 



57 

The sagittal suture inclines towards the 
back of the pelvis. 
This kind of labour is not in general very- 
unmanageable. The head may be longer than 
ordinary in passing through the pelvis; but if 
this be well formed, and the pains are strong, it 
will be at length excluded, and in the majority 
of cases the child will be born alive. 

It is necessary to pay particular attention, to 
prevent a laceration of the permasum: for the 
external parts are excessively stretched when 
the head passes in this direction. Even women, 
who have borne many children, have had the 
perinaeum lacerated, under the circumstances of 
this kind of presentation.* 



is inclined to take an unfavourable position or that of 
the forehead towards the pubes. — Ed. 

* This presentation may be rectified and the progress 
of the labour accelerated, by applying the fingers to the 

H 



58 

2. The presentation of the face (b), may be 
known by the general inequality of the present- 
ing part, and by the distinction of the eyes, nose, 
mouth, and chin. 

When the face is the presenting part, the 
most favourable, and according to Dr. Den- 
man the most usual position, is with the chin 
towards the symphysis pubis. 

The management of this case must in a great 
measure be left to nature and time, which will 



side of the forehead, and carefully pressing the anterior 
fontanelle from the acetabulum which it approaches to 
the sacro-iliac symphysis of the same side of the pelvis 
—by which operation the occiput is ultimately brought 
under the arch of the pubis — and the dangers and diffi- 
culties above enumerated, obviated. 

In the progress of the foetal head through the pelvis, 
this malposition is sometimes rectified by nature herself, 
without the> assistance of art. — Ed. 



59 

gradually effect the delivery: but the bones of 
the face not being capable of compression, do 
not yield to the form of the pelvis, and therefore 
very often many hours elapse with but little 
perceptible progress. The children are usually 
born alive, but the features of the face are 
amazingly distorted, and do not recover their 
proper appearance sometimes for many days. 

We have been directed, to get a finger into 
the mouth of the child, and to press down the 
chin upon the breast, or in any other manner, to 
endeavour to alter the position of the head. 
There is, however, but little probability of 
doing good by this manoeuvre, and some hazard 
of doing mischief. 

It has been strongly recommended, among 
others by Smellie, Burton, and Cooper, to turn 
and deliver footling in face cases : and this prac- 
tice was enjoined upon the supposition that the 
life of the child would be sacrificed, unless the 



60 

labour was quickly terminated: but experience 
has shown in this and many other points of 
practice, that the safety of the child is not 
always commensurate with the quickness of 
the labour. 

3. Independent of the awkwardness of posi- 
tion, which the head may assume from the cir- 
cumstance of the hand or arm descending with 
it into the pelvis (c), there will be so much 
increase in the bulk of the part, as to render its 
passage slow and difficult. Yet, if the case be 
not interrupted by mismanagement, it will 
terminate favourably; for this complication of 
presentation seldom happens but in a wide 
pelvis. 

There will be some difference in the diffi- 
culty of the labour, according to the manner in 
which the superior extremity enters the pelvis. 

If it be only the fingers or hand coming down 



61 

in a flattened shape, by the side of the head, the 
difficulty will not be very great. If the elbow be 
the part, with the fore- arm bent back upon the 
humerus, the difficulty will be increased. And 
it will be still more perplexing, if the hand and 
arm have descended before the head, the head 
resting upon the arm, at the bend of die elbow. 

Occasionally it will be practicable, by means 
of the operator's fingers, to prevent the hand or 
arm from descending below the brim of the 
pelvis, till the head has sunk so low as to be 
clear of the impediment: but in attempting this, 
care must be taken, not to make the case more 
embarrassing by drawing the arm down lower, 
or forcing the head above the brim of the pelvis; 
for this might convert the case into a truly pre- 
ternatural labour, and render the turning of the 
child necessary. 

The arm of the child is often very much 
bruised and tumefied in consequence of this 



62 

position, and it is sometimes difficult to persuade 
the attendants that it is not fractured or dis- 
located. I have not, however, known an in- 
stance, in which the arm did not recover itself 
in a few days. 

The rules laid down for the management 
of labours of the order dystocia diutina, are 
applicable to those of dystocia perversa. In both, 
the labours are painful, difficult, and slow: yet 
in both, the efforts of nature are usually sufficient 
to effect the delivery without artificial assistance, 
or at least, with that assistance, which a single 
finger may give. 

Care must be taken to preserve the patient 
from fever, to keep her spirits calm and undis- 
turbed, and to husband her strength; she should 
not be permitted to fatigue herself in vain 
attempts to force the child forwards, before the 
parts are properly prepared to let it pass; nor 
©ught she to be kept too much in bed, lest she 



63 

be weakened by profuse perspirations under a 
load of bed clothes. Her bowels must be occa- 
sionally relieved, by laxative medicines or clys- 
ters, and the urine must not be suffered to 
accumulate in the bladder.* Under such treat- 
ment the process of parturition may continue 
for a long time without hazard. 

If, however, the favourable symptoms of 
labour before enumerated (p. 50) gradually dis- 
appear, and those which are unfavourable begin, 
we must consider this order of labours to be 
.degenerating into dystocia anenergica, and must 
adopt such measures, to insure our patients 
from danger, as the nature of the case may 
require. 



* Perhaps there is a particular tendency to suppres- 
sion of urine in face presentations; at least I have found 
this inconvenience to happen in several labours of this 
nature to which I have been called. 



64 



Order 4. Dystocia Amorphica — Labour render •- 
ed difficult from Deformity in the Bones of 
the Pelvis. 



Dystocia ab Angustia. Sauvages, CI. 7, O. 26, § 4. 
Dystocia Amorphica. Young, CI. 5, O. 77, § 4. 
Laborious or Instrumental Labour. CI. 5. Burns. 
Impracticable Labour. CI. 6. Burns. 



Distortions of the pelvis may arise — 
from rachitis in infancy. 

from malacosteon in more advanced life. 

from exostosis. 

from fracture or dislocation of the bones of 
the pelvis. 

From whichever of the above causes the 
deformity proceeds, the capacity of the pelvis 



65 

will be so much intrenched upon, as to oppose 
an impediment to the passage of the child, not 
only in first but in all future labours. 

Yet sometimes the efforts of the uterus will 
be sufficient to force the child with the head 
much compressed through the deformed pelvis. 
Much in such cases will depend upon the small- 
ness and compressibility of the head, and the 
strength of the pains. 

It becomes us to be exceedingly cautious not 
to suppose upon light and insufficient grounds 
that the distortion is too great to allow the child 
to pass without the intervention of instruments; 
and particularly when there is a question about 
employing the perforator, an instrument always 
incompatible with the life of the child, we ought 
to weigh every circumstance very carefully in 
our minds, and if possible procure the opinion of 
some other experienced practitioner, before we 

i 



66 

determine upon having recourse to it. The ex- 
istence of a human being depends upon our 
decision, we ought not therefore to decide but 
with the greatest deliberation and wariness: 

Nulla unquam de fnorte hominis cunctatU longa est. 

Juvenal, sat. 6. 

The reluctance, which every well-regulated 
mind must feel, at employing the perforator 
even in cases of the greatest necessity, while 
the infant is yet living, naturally occasions a 
wish to delay the operation, till there are some 
indications of the child's death; and these indi- 
cations are sought for, in certain symptoms, 
which most writers on midwifery have been 
careful to enumerate. 

These symptoms may be divided into two 
classes; the first are useful in proving that the 
fetus has been dead in utero for several days or 
even weeks. 



67 

These symptoms are: 

Severe shivering fits on the part of the 
mother, followed by 

a sense of coldness in the abdomen; 

a feeling as of a lump, or dead weight, in 
the uterus; 

a subsidence of the abdomen; 

a want of motion in the child; 

a flaccid state of the breasts; 

a recession of the milk. 

But this is not what is commonly wanted. 
The object is to ascertain whether the child, 
which was known to be living when the labour 
commenced, has afterwards lost its life from 
the violence of the pains, or the severity of the 
labour. And this is to be judged of from the 
second class of symptoms, which are however 
more or less fallacious. I shall enumerate seve- 



68 

ral of these, and offer some comments upon 
them as I proceed: 

1. " If the woman be four days in labour, the 
child scarce escapes." 

This is given upon very indifferent authority, 
that of Culpeper, and is never to be relied upon 
in cases of well-formed pelvis; but when the 
pelvis is much distorted, a labour of less than 
four days continuance is often destructive of the 
child. 

2. An evacuation of the meconium during 
the labour. 

Viardel considers this as a decisive proof of 
the child's death, but very improperly; since in 
nates presentations, a discharge of the meconium 
always happens, yet in the majority of cases the 
child is born alive. Many authors have refuted 
this opinion of ViardeL 



69 

Others have supposed, that when the meco- 
nium is discharged in presentations of the head, 
a pretty certain proof of the child's death is 
obtained, but many instances to the contrary 
have occurred. 

3. A fetor, and an ill appearance of the 
discharges from the uterus. 

These symptoms are not wholly to be de- 
pended upon; but when they accompany others, 
are not to be disregarded. 

4. A want of pulsation in the navel string. 

The proof here is conclusive, but opportuni- 
ties of examining the navel string are compara- 
tively rare.* 



* I do not consider this symptom so entirely conclu- 
sive as it appears to our author. — I have known a tern- 



70 

5. An edematous or emphysematous feel of 
the scalp, with the bones of the cranium 
separated and loose. 

These may likewise be considered as conclu- 
sive proofs of the child's death. 

6. A want of motion in the child is often re- 
lied upon, and ought to be enquired about 
in all doubtful cases, because if the mo- 
tions of the child are really felt, it cannot 
be dead. But very often the mother does 
not feel the child to move for many hours 
together during labour, and yet it is often 



porary suspension of the pulsation in the funis, where 
the child was born alive; and a case occurred to me 
where the pulsation had ceased for a considerable time, 
the child being apparently still-born, where neverthe- 
less, upon having recourse to the proper means of resus- 
citation, the pulsation returned — the child recovered — 
lived between one and two days, and once took the 
breast. — Ed. 



71 

born strong and healthy; want of motion 
therefore, in the child, cannot alone be 
considered as proving the child's death: 
but, joined with other symptoms, it will 
materially assist the practitioner in forming 
his opinion. 

[A deformed pelvis is said, by the most intelligent 
travellers, to be unknown among the female aborigines 
of our continent — and it is a very happy circumstance, 
that it is a very rare occurrence among the women 
born and educated in the United States. This will be 
readily understood by the medical reader. Children 
and women in this country, are not subjected to so many 
causes producing Rachitis and Malacosteon: such as 
scanty and bad food, sedentary confinement in crowded 
manufactories, and other debilitating processes so com- 
mon in Europe. — Hence the propriety of pausing and 
reflecting, before ever having recourse to the operation 
of Embryulcia, the necessity of which must be so ex- 
ceedingly rare in our happy country.]— Ed. 






Order 5. Dystocia Obturatoria — Obstructed 
Labour. 



Dystocia ab Angustia. Sauvages, § 4. 
Dystocia Amorphica. Young, §4. 



Definition, — Labour rendered difficult, by a 
mechanical obstruction in the soft parts, 
to the passage of the child. 

a. by the presence of the hymen, or by a 
cohesion of the labia, or of the vagina. 

b. by a polypous, steatomatous, or other 
tumour growing from the organs of 
generation, and obstructing the passage. 

c. by a diseased ovarium, intrenching upon 
the capacity of the pelvis. 



73 

d. by a protrusion of the bladder into the 
vagina. 

e. by a portion of intestine or omentum, 
forming a hernia in the vagina. 

1. All the species of this order of labour are 
of very rare occurrence. Those of the first kind 
(a) will not probably occasion much embarrass- 
ment to the accoucheur; the action of the uterus 
will alone be sufficient, in most cases, to over- 
come the difficulty.* Should it, however, be 
found necessary to do more, an incision must 



• Fui ego adTOcatus ad raulierem parturientera. cui 
ragina adeo erat angusta, utnec ego, nee G05te:rix du-i:i 
minimi apicem potuerimus vaginae immnere, maritus a 
triennio, quo ipsi matrimonio erat junctus, nunquam 
more solito coitum exercere cum ilia potuit. Interim 
tamen spatio 18 horarum dolores parturiuonis vaginam 
adeo dilatabant, ut partus sine omni ruptura vaginae, vel 
genitalium finiretur. 

PUnck Elrmer.:z ArtU Obaeirici*, p. 113, 
K 



74 

be made through the obstruction; very great 
care being taken not to wound or injure any 
contiguous part. 

I have met with one instance only of the pre- 
sence of the hymen during parturition. 

2. Tumours growing from the organs of 
generation (b) are sometimes so small and 
compressible as to occasion little or no impedi- 
ment to the passage of the child. But, occasion- 
ally, they have been found to occupy so large 
a space as to render delivery impossible without 
the intervention of art. 

Should the case be such as to allow the diffi- 
culty to be overcome by employing the forceps 
or vectis, there could be no hesitation in having 
recourse to either of these instruments. But if 
there be no chance of succeeding with any 
instrument, short of using the perforator, it 
would be right to pause, and to consider 



*3 



whether to remove the tumour, or to diminish 
the size of the child, would be most likely to 
be attended with ultimate advantage; and so 
much will then depend upon the size, situation, 
and nature of the tumour, that it is impossible 
to lay down exact rules upon the subject.* 

3. Cases of diseased ovarium, intrenching 
upon the capacity of the pelvis, have been 
mentioned by several writers on midwifery, f 
Should the ovarian tumour be occasioned by 
an accumulation of fluid, it would probably 
be better practice to puncture the tumour and 
evacuate its contents, than to diminish the size 
of the child's head. 



* See " Two Cases of Tumours in the Pelvis, ifc. by 
P. P. Drew, M. D." in the Edinburgh Medical and Sur- 
gical Journal, vol. i. p. 20. 1805. 

t Denman's Midwifery, 4to. p. 324. — Baudelocque\ 
Midwifery, § 1963. — Medico-Chirurgical Transactions, 
vols. ii. and iii. 



76 

It is however of the utmost consequence to 
be well assured that the tumour is ovarian, and 
not a protrusion of the vesica urinaria into the 
vagina (d)*, which may he always ascertained 
by passing a catheter; nor a hernia of the intes- 
tines (e), which will be relieved by procuring 
stools. 



* See " Hamilton* s Select Cases in Midwifery** p. 9. 
1795; and a very instructive paper by Mr. Christian, in 
the Edinburgh Medical Journal, vol. ix. p. 281. 



77 



Order 6. Dystocia Ectopica — Difficult Labour 
from Displacement of the Uterus. 



Uterus Obliquatus. Deventer. 

Hysteroloxia Anterior — Lateralis— -Poste- 
rior. Sauvages. 

Hysteroloxia Lateralis. (Imperfecta). 

< Antica— — Postica — (Perfecta), 

Plcnck. 



Most authors enumerate three species of 
obliquity of the uterus. 

a. The os uteri inclined towards one or 
the other side of the pelvis. 

b. The os uteri tilted up backwards, so 
as almost to reach the projection of the 
sacrum. 



78 

c. The os uteri projected forwards, above 
the symphysis pubis. 

1. The lateral obliquity* of the uterus (a) can 
scarcely prove a cause of difficult labour; an 
erect posture will, if the pelvis be well formed, 
speedily rectify this displacement. [Or laying 
on the opposite side to the obliquity.] 

2. The os uteri, tilted backwards towards 
the projection of the sacrum (b), is not a very 
unusual occurrence in women with wide pelves, 
and it almost always occasions a slow labour. 

Young practitioners are apt to be embarrass- 
ed, when thev find the uterus thus situated: for 
upon an examination per vaginam, the pelvis at 
first seems to be filled up by the head of the 
child making a rapid advance towards delivery. 
A more accurate examination, however, shows 
that the part, in contact with the finger, is not 
the naked head of the child, but the anterior 



79 

surface of the uterus spread over ir. And the 
os uteri scarcely at all dilated, will with some 
difficulty be discovered towards the projection 
of the sacrum, almost beyond the reach of the 
finger. 

This kind of difficult labour is best reliered 
by time and patience. It has been thought 
advantageous for the patient to take her pains, 
lying on her back. The method proposed by 
some authors, of insinuating a finger into the 
os uteri, and drawing it towards the centre of 
the pelvis, is liable to many objections. 

3. The os uteri projected above the sym- 
phy sis pubis is a very rare occurrence. Dev enter 
describes this situation of the uterus, but he 
does not seem to have had a very correct idea 
of the case. Since his time many authors have 
denied the possibility of such an occurrence; 
but there are several cases upon record which 
prove the fact. It is a retroversion of the uterus 



80 

continuing to the full period of pregnancy.* Of 
this case I have known two instances. 

4. Another kind of displacement of the uterus 
has been spoken of by authors, f but I have 
never known an instance of it. 

d. The os and cervix uteri sunk without 
the os externum during labour. 



* See " Cautions to Women, respecting the State of 
Pregnancy, &c. By S. H. Jackson, M. D." p. 59, 1798. 
—Also, U A Dissertation on the Retroversion of the 
Womb" By the Author of this " Synopsis" 

f Medical Museum, vol. i. p. 227. 1763. — Memoirs of 
the Medical Society of London, vol. i. p. 213.— .Medical 
and PhysicalJournal, vol. i. p. 154. 



81 



Order 7. Dystocia Transversa — Preternatural 
Labour. 



Dystocia a Foetus Situ. Sauvages, § 7. 

Perversa. Young, § 3. 

Unnatural Labour. Bland. 

Preternatural Labour. Smellie. Denman. Burns. 

Accouchement contre Nature. Baudelocque. Gar- 

dien. 
————— Manuel. Capuron. 



Definition. — Labour in which any part of the 
child presents, except the head.* 



* M. M. Baudelocque, Gardien, Cafiuron, and other 
French practitioners, do not consider the labour to be 
preternatural, though the nates, the feet, &c. present, 



82 

Authors have enumerated a great variety of 
preternatural presentations, but they may be all 
resolved into the following: — 

a. Presentations of the nates, or of either hip, 
or of the loins. 

b. Presentations of the inferior extremities, 

c. superior extremities. 

d. back, belly, or sides. 

e. funis umbilicalis. 

Preternatural labours can only be known by 
an examination per vaginam. 

If upon such an examination it should be 
ascertained that the os uteri is considerably 



provided that it terminates without the extraordinary 
assistance of the accoucheur. Unless his assistance is 
required, it is still according to them unassisted (or 
natural) labour. 



83 

dilated, and the child cannot be felt, this affords 
reason to suspect that the presentation is preter- 
natural. Should the liquor amnu be discharged 
and the child be out of reach of the finger, the 
probability of a preternatural position is greater. 

Should the membranes be found hanging 
down in the vagina, not of the usual globular 
form, but rather conical and small in diameter, 
this likewise is a presumptive proof of a cross 
birth; especially if the part presenting through 
the membranes " be smaller, feci lighter, or 
give less resistance when touched, than the 
bulky heavy head." 

These, however, are but probable signs; we 
cannot positively ascertain the fact, but by accu- 
rately examining the presenting part. 

Whenever there are presumptive signs of a 
preternatural presentation, it becomes our duty 
to be very watchful of our patient, that we may 



84 

be prepared to give the necessary assistance if 
it should be required; and when we have fully 
satisfied ourselves that the child is coming in a 
wrong direction, we ought to inform some of 
the patient's friends of the circumstance; but it 
is best to conceal it from herself as long as 
possible. 

There is sometimes much difficulty in ascer- 
taining what the presenting part is. Yet it is 
often of the greatest importance not to make a 
mistake, particularly in the presentation of the 
extremities. The hazard of a mistake is greatest 
when only one extremity presents. 

The following rules -will in general enable us 
to form a correct opinion: — 

The head is known by its globular form, and 
hardness. 

by the sutures and fontanelles. 



85 

The face, by the inequality of its surface. 

by the eyes, nose, mouth and chin. 

The nates, by the softness, pulpiness, and 
globular shape. 

by the cleft between the buttocks. 

by the parts of generation. 

by the evacuation of the meconium. 

The foot, by its thickness, 
by the heel, 
by the great toe. 
by the shortness of the toes, 
by the ends of the toes forming 
nearly an even line. 

The hand, by its flatness. 

by the length of the fingers. 

by the unevenness of the ends of the 
fingers. 

by the thumb bending into the palm 

of the hand. 



86 

The elbow has sometimes been mistaken for 
the knee or the heel; it may be distinguished 
by being more pointed than either of these 
parts. 

The shoulder may be known by the clavicle 
and scapula; but generally when the shoulder 
presents, the arm is found in the vagina. 

1. Of the presentation of the nates (a). 

In early labour, this presentation is not always 
easily distinguishable from that of the head, on 
account of the globular feel of both parts. 

Labours of this kind were formerly very much 
dreaded, as it was supposed that there was not 
room for the child in this doubled position to 
pass through the pelvis. Hence the older 
accoucheurs attempted to turn the child, and 
bring the head to present. Afterwards, upon the 
authority of Ambrose Pare, it became the prac- 



87 

tice to push up the nates, and bring clown the 
feet, thus converting the case into a feet presen- 
tation.* Burton strongly recommends this prac- 
tice, and Smellie too often adopted it, but it is 
never necessary except in cases of distorted 
pelvis. 

The nates may enter the pelvis in various 
directions; sometimes one hip only descends 
through the superior aperture, sometimes the 



* Partus naturalis et facilis is demum censetur, quo in 
caput infans prodit, aquarum effluxus sine mora sequu- 
tus; difficilior est quo in pedes prodeunte foetu fit: reliqui 
wanes difficilimi. Itaque obstetrices monendae sunt, ut 
quoties neutro commemoratarum partium prodire infan- 
tem cognoverint, sed vel in dorso, vel in ventrem, vel In 
pedes manusque simul, vel in porrectum brachium, vel 
quavis alia denique contra naturam forma, ipsum conver- 
tant et in pedes trahant: cui operi perficiundo si ipsae 
non sufficiant, chirurgum exercitatum accersant. Parai 
de Horn. General, cap. 15. 

This seems to be the first positive injunction to turn 
and deliver footling in preternatural labours. 



88 

child lies with its face towards the mother's 
belly, and at other times it is turned towards 
her back, and this is the most favourable po- 
sition. 

The first stage of labour in nates presenta- 
tions is frequently very slow, for though the 
nates and thighs do not take up so much room 
as the head, yet either they do not readily adapt 
themselves to the shape of the pelvis, or the 
action of the uterus is slower or less regular, in 
consequence of the awkward position of the 
fetus. No means, however, can with propriety 
be employed to hasten the progress of the 
labour; and by degrees the dilatation of the parts 
is effected, and the nates are forced lower and 
lower into the pelvis, till at length they protrude 
through the os externum. 

As soon as this has happened, the case becomes 
precisely the same as a footling presentation, and 
is to be managed exactly in the same way. For 



89 

further rules for the management of nates 
presentations, see the next section, p. 97. 

The danger to the mother in nates presenta- 
tions is not great; the danger to the child is 
considerable: but if the case be well managed, 
the life of the child need not be so often lost as 
has been supposed. 

Paul Portal, who was a celebrated accou- 
cheur at Paris from 1664 to 1682, says, that 
80 out of 100 children, presenting in this man- 
ner, will be born alive. Portal gives very judi- 
cious directions for the management of this 
kind of labour; but his instructions were 
disregarded by subsequent practitioners and 
writers. 

His words are, 

"In such a case as this, you must not be 
impatient, for though the labour proceeds very 
slowly, yet it is not much more difficult than a 

M 



90 

natural birth: whence it is that our mid wives 
say by way of proverb, that where the buttocks 
can pass, the head will follow of course. The 
position of the child in this case is doubled, with 
his thighs upon the belly, and the passage being 
once opened for the buttocks by the reiterated 
pains, the head follows without much trouble.' >* 

I cannot help contrasting these judicious 
directions with those of our countryman, Dr. 
John Burton, of York, the cotemporary and rival 
of Smellie; who says, $ 89, " When the buttocks 
come foremost, it sometimes happens (though 
very rarely) that it may be brought in this pos- 
ture, if the child chance to be very small, and 
the passage large: but yet this is very accidental; 
for though we may discover the passage to be 
large, yet we cannot so easily judge of the child's 



* « Complete Practice of Men and Women Midwives f 
Vc. by Paul Portal, Sworn Surgeon, and Man-midwife in 
Pari*," p. 23. 



.91 

bulk, and therefore we should attempt to bring 
it forth by the feet, as directed, } 88." The 88th 
section runs thus, " When the buttocks come 
foremost, the more it is suffered to advance, 
the more dangerous and difficult will be the 
labour: therefore as soon as the operator per- 
ceives, by the softness and fleshiness of the 
parts, what part presents, he must immediately 
thrust up against the buttocks with all his 
strength, but without committing violence to 
the child's os coccygis, or its parts of generation, 
which are often in this case swelled; and as he 
thrusts up, he must endeavour to turn the child 
with its belly towards the os uteri, and then 
search for the feet."* 

Were this rough and barbarous recommen- 
dation of Burton generally followed, the most 



• « New and Complete System of Midwifery, by John 
Burton, M. D." 1752. 



92 

lamentable consequences, both to mother and 
child, could not fail of being often experienced* 

Many writers on midwifery recommend, in 
nates presentations, when the buttocks do not 
readily pass through the pelvis, to insinuate a 
finger on each side, as high as to the groins of 
the child, and thus to assist the delivery. This 
mode of practice is very seldom necessary, and 
not always safe. 

It has likewise been recommended, when the 
groins are beyond the reach of the finger, to 
introduce a blunt hook, by which to extract the 
child: but though in the course of my practice I 
have attended very many cases of nates presen- 
tations, I have never yet found it necessary to 
have recourse to this expedient.* 



♦Notwithstanding what our author says here, and 
although it may not be often necessary to have recourse 



93 

2. Of presentations of the inferior extre- 
mities (b). 

This is the most simple, and probably the 
safest to the mother, of all the preternatural 
positions: but the hazard to the child is con- 
siderable, particularly if it be a first labour. 

The danger to the child arises principally 
from the compression of the navel string between 
its own head and the parts of the mother, as the 
child passes through the pelvis. 

The great object of the accoucheur, then, 
is to prevent this compression; and this is to 



to any artificial aid in breech presentations, yet such 
cases do sometimes occur, and when they do, the blunt 
hook is the proper instrument to employ. In careful and 
judicious hands, if properly made, it may be used with- 
out injury to the child or mother. It should generally 
be applied to the groin which is nearest the sacrum of 
the mother. — Ed. 



94 

be effected, by getting the head of the child 
through the pelvis, with all proper expedition, 
as soon as the body of the child is born. 

In order for this, it is not necessary to hasten 
the delivery of the body of the child: on the 
contrary, it is desirable, that the delivery of the 
body should be effected slowly; for thus the 
parts of the mother will become more dilated 
and spacious, and of course there will be less 
resistance opposed to the passage of the head. 

But if attempts are very early made to reach 
the feet, and to expedite the delivery by draw- 
ing them down, and afterwards to extract the 
body rapidly, it will probably be found, when 
the head comes to occupy the pelvis, that the 
soft parts of the mother will be too rigid to let 
the bulky head pass through them; and thus so 
much delay will take place, as to destroy the 
child. 



95 

If, therefore, at the beginning of the labour, 
the membranes should be entire, let great care 
be taken not to rupture them, till all the dilata- 
tion that can be effected by the pressure of the 
bag of waters is produced. 

Or if the membranes should be ruptured, 
and the feet are felt naked in the vagina, let no 
hasty attempt be made to extract by them: it 
will be better to leave the case entirely to nature, 
till the nates have passed through the os exter- 
num; by which time the parts will be dilated as 
much as circumstances will allow. 

But when the nates are born, the attention of 
the accoucheur is demanded. 

In order that the head of the child may pass 
conveniently through the pelvis, it is necessary, 
that it be so inclined, as for the forehead to 
occupy the hollow of the sacrum, after the head 
has passed through the superior aperture. The 



9% 

long diameter of the head must, therefore, first, 
be in the direction of the long (or transverse)* 
diameter of the pelvis, and afterwards the fore- 
head will fall into the hollow of the sacrum. 

It becomes us then, carefully to attend to the 
position of the child; and this is ascertained by 
examining the feet. If the toes are turned 
towards either sacro-iliac synchondrosis, the 
child is already in a right direction: for when 
the forehead has passed through the superior 
aperture of the pelvis, it will naturally slide into 
the hollow of the sacrum, and the passage of the 
head through the pelvis will be much facilitated. 

But if the toes point to the symphysis pubis \ 
or belly of the mother, the head will come in 
an unfavourable position: it will not readily 
adapt itself to the shape of the pelvis: probably 



* Or more properly the oblique. 



97 

in passing, the chin will hitch upon the ossa 
pubis, and it will be difficult to extricate it from 
this untoward situation. 

To guard against this accident, it will be 
proper, as soon as the nates* have passed 
through the os externum, to take hold of both 
thighs with a warm napkin; and, when the next 
pain comes on, to give such an inclination to the 
body of the child, by guiding it with the hands, 
as will direct the face towards the mother's 
spine. 

There is no difficulty in effecting this turn, 
if it be done prudently and cautiously. Much 
force is not required; nor is it necessary that 
the child's belly be turned quite round to thw 



* The following rules are applicable, as well to cases 
where the nates is the presenting part, as where the feet 
first come down. 

N 



9$ 

mother's back: an inclination towards the back 
is all that is wanted. 

During the pain, which, with the assistance 
of the accoucheur, produces this turn of the 
child, it is probable that the whole of the body- 
will be expelled, and nothing will remain in the 
pelvis but the child's head, with the arms 
extended on each side above it. 

It has been a question much discussed, 
whether it be best in preternatural cases to 
finish the delivery, leaving the arms thus ex- 
tended on each side of the head, or to draw 
them down by manual assistance, before any 
attempt is made to bring the head into the 
world. 

It has been given as a reason for not bringing 
down the arms, that while they are in this 
situation, the os uteri is prevented from con* 
tracting round the neck of the child, and thus 



$9 

impeding the passage of the head. But if the 
early part of the labour has been permitted to 
proceed sufficiently slow, to allow the os uteri 
to become properly dilated, such a contraction 
is little to be dreaded; and the arms need not be 
suffered to remain for this purpose. I believe, 
that a contraction of the os uteri round the neck 
of the child, never takes place after the os uteri f 
has once been completely dilated. 

Another reason given for not bringing down 
the arms, is, that while they are thus extended 
above the head, the navel string is secured from 
pressure: but I do not understand how the 
pressure can be diminished, by having the bulk 
of the parts passing through the pelvis increased. 

A far better reason for not bringing down the 
arms, is, the danger of dislocating or fracturing 
them; and, if the practitioner will be so heedless 
and imprudent, as to use undue force and vio- 
lence in extracting them, this danger will be 



100 

imminent: but if the attempt be cautiously and 
judiciously made, no hazard need attend this 
operation. 

The operation consists in passing the finger 
over the shoulder of the child as far as to the 
bend of the elbow, which is then to be gently 
depressed, and the fore arm commonly passes 
through the vagina without much difficulty. 
One arm being brought down, the extraction of 
the second becomes more easy. 

In proportion to the rigidity of the soft parts 
will be the difficulty of the extraction: should it 
be found that the operator's finger can not reach 
the bend of the elbow, or does not readily dis- 
lodge the arm, it will be better to defer the 
attempt, or to give it up altogether, rather than 
to do injury to the infant. With first children, 
it will require some care to guard against a 
laceration of the perineum, as the arm passes. 



101 

When the labour has proceeded so far, that 
only the head remains to be born, we are to 
extract this with all the speed that circum- 
stances will admit; for if it remains long in this 
position, the compression upon the funis will 
be so great, as speedily to cause the child's 
death. 

It is of importance to get a finger of the left 
hand introduced into the child's mouth. This 
serves two valuable purposes: — 

1st. By this means we have it in our power 
to depress the chin, which alters the position of 
the head, and adapts it more commodiously to 
the pelvis, 

2dly. By opening the mouth of the child, it 
will sometimes happen, that a portion of air will 
make its way into the lungs sufficient to distend 
them, and partially establish the function of 



102 

respiration: by which the life of the child may 
be somewhat prolonged. 

If the finger be properly passed into the 
child's mouth, the arm and hand of the opera- 
tor serve to support the body of the infant in 
such a direction as tends to facilitate the expul- 
sion of the head. 

The fore finger of the left hand being insi- 
nuated into the mouth of the child, the fore and 
middle fingers of the right hand should be 
passed over the nape of the neck, one finger 
resting on each shoulder; and now a moderate 
extracting force may be employed to bring forth 
the head. This will sometimes be more conve- 
niently done, if the woman be turned upon her 
back, and if the operator stands while making 
the extraction. 

It is desirable that this attempt be made 
during a natural pain, and that the operator cease 



103 

from his attempt as soon as the pain goes off: 
but if the case be urgent, the extraction must 
be made without waiting for the natural pains. 

The necessity for hastening the extraction of 
the head, as has been already remarked, is to 
preserve the life of the child; but so long as a 
pulsation is to be felt in the navel string, the 
child's life is in no danger. 

It has happened not uncommonly, that the 
eager desire of the operator to save the life of 
the child has defeated its own purpose; for if 
he is led to use too much force, he may thereby 
strain the child's neck, and thus injure it; or, if 
he keep the parts constantly upon the stretch, 
he will so completely compress the funis, as 
entirely to interrupt the circulation through it, 
and of course produce the death of the child: 
whereas, if he were to desist occasionally from 
dragging, the pressure on the funis would be 



104 

diminished, and the circulation might be pre- 
served.* 

3, Of presentations of the superior ex- 
tremities (c). 

There are no presentations more dangerous, 
or more difficult to manage, than those of the 
superior extremities; for whether the part pre- 
senting be the hand, the elbow, the shoulder, 
or both hands, it is clearly impossible that a 
full-grown fetus should pass through the pelvis, 
unless this position be altered. 

It was the practice of the ancients to endea- 
vour to push back the arm, and bring the head 
into the pelvis; but this method could seldom 



* Add to this, that by too hasty and injudicious ex- 
ertion, of the practitioner, the danger of lacerating the 
perinaeum is increased.— E» f 



105 

succeed, and it was, after a time, laid aside, 
principally upon the authority of Ambrose Pare, 
who directed that the feet should be sought for, 
and brought down, in all preternatural presen- 
tations. 

It seems now universally agreed, that the 
preferable mode is to turn and deliver footling; 
for though it is sometimes practicable to return 
the arm, and bring the head to present, yet the 
chance of success in this way is very trifling.* 

The established practice, then, is for the 
operator to pass his hand into the uterus, to take 
hold of the feet, and bring them without the os 



* Guitlemeau, however, the pupil of Pare^ directs the 
operator first to try to bring the head into the pelvis, 
and if he cannot succeed in this, to seek for the feet; 
and Bracken speaks of this operation as very easy; but 
he is mistaken. 



106 

externum; thus converting the presentation of 
the arm into a presentation of the feet. 

Though the necessity of effecting this altera- 
tion in the position of the fetus is generally 
subscribed to, and though it is by all admitted, 
that the turning should be accomplished as 
speedily as possible; yet it is not always in our 
power to proceed to the operation, as soon as the 
nature of the case is ascertained. 

A variety of circumstances may be present* 
in this kind of preternatural position, which 
will occasion embarrassment to the operator, 
and add more or less to the difficulty and danger 
of the case. It is not my intention to enumerate 
every possible difficulty; but I shall offer a few 
observations on the method ©f proceeding in 
four different cases, which will be sufficient to 
enable the young practitioner to regulate his 
method of management in all others. 



107 

1st. If it should be ascertained, before the 
membranes are ruptured and the waters dis- 
charged, that the arm is the presenting part, it 
will be right not to attempt to introduce the 
hand, till the os uteri is sufficiently dilated, to 
allow the hand to pass with ease into the uterus. 
For till the membranes are ruptured, no danger 
exists, and the dilatation of the parts is more 
easily and conveniently effected by the bag of 
waters, than by any other means. 

As soon as the os uteri is sufficiently dilated, 
(and the more complete the dilatation cf this 
part the more safe will be the delivery), the 
operator must dilate the external parts artifi- 
cially, till they oppose no further resistance to 
the introduction of his hand. Then slowly car- 
rying his hand through the vagina, to the 
os uteri, he must gently insinuate it through 
this part in the absence of a pain. He must, 
now, rupture the membranes by pressing a 
finger firmly against them; when his hand will 



108 

immediately come in contact with the body or 
limbs of the child. He is then to pass his hand 
forwards till he reaches the feet, -which he should 
draw down along the belly, not over the back of 
the child\ and proceeding slowly he will find, 
that as the feet are brought lower, the present- 
ing arm will be retracted; and when the nates 
are brought to occupy the hollow of the sacrum, 
the arm will be drawn completely within the 
uterus. The case now becomes precisely simi- 
lar to a feet presentation, and is to be managed 
accordingly. 

This is the easiest and safest case of turning, 
for the uterus is kept distended all the time by 
the liquor amnii, which, after the membranes 
are ruptured, is prevented from passing off by 
the operator's hand plugging up the vagina and 
os externum. So that the efforts of the accou- 
cheur to turn, are not impeded by the contrac- 
tion of the uterus upon the body of the child. 



109 

In all cases therefore where it is known, or 
suspected, that the arm is the presenting part, 
and the membranes remain entire, it becomes 
us to watch the patient with great assiduity, in 
order that we may take our own opportunity 
for turning, before the waters are evacuated. 

2. Sometimes it will be found, that the arm 
is lying in the vagina, or without the os exter- 
num, the liquor amnii having been some time 
discharged, the os uteri nearly or quite dilated, 
and the patient either quite free from pains, or 
having pains seldom occurring. Here is another 
case in which it is advisable to proceed without 
delay to deliver by turning the child: but the 
turning will not be so easily effected in this, as 
in the former case, because the uterus will be 
in a state of contraction on the body of the 
child. There will therefore be greater difficulty 
in passing up the hand to reach the feet. Still 
if there be only the passive contraction of the 



110 

uterus,* the delivery may be effected without 
much trouble. 

The hand is to be passed cautiously through 
the os externum, care being taken to have this 
part sufficiently dilated. It must then be in- 
sinuated in the most gentle manner through the 
os uteri, and slowly conducted over the surface 
of the child, till it reaches the feet. These are 
then to be slowly drawn down into the vagina, 



* By passive contraction, I mean that contraction of 
the uterus, which always takes place, in consequence of 
the discharge of the waters, and which may be consi- 
dered " as the exercise of that inherent disposition, by 
which efforts are made by the uterus to recover its 
primitive size and situation, when any cause of disten- 
tion is removed:" this passive contraction admits of 
different degrees of intensity. 

By active contraction, I mean the occurrence of strong 
muscular action, whether regular as in labour pains, or 
irregular as in spasm. 

See jDcnman't Introduction to Midwifery, 4to. p. 440, 



Ill 

and finally without the os externum. Should 
uterine action be excited during the time that 
the hand is in the uterus, it must be kept in a 
flattened form close upon the body of the child; 
or may be a little withdrawn while the pain 
continues; and when the pain has subsided the 
hand may again be cautiously carried forwards. 

It is generally more difficult in this than in 
the former case to lay hold of both the feet; 
we must sometimes therefore be content with 
one only, but the turning is always much more 
safely and easily accomplished, when we can 
command both feet, than when we have only 
been able to reach one, 

3. Again, it may happen, that a superior 
extremity presents, the liquor amnii is e vacua* 
ted, and the os uteri but little dilated, perhaps 
very firm and rigid. In this case it will probably 
be found necessary to wait with patience till the 
paru become more relaxed or dilated: for as 



112 

there would of course be great resistance to the 
introduction of the hand, it is probable that the 
attempt to force it into the uterus would excite 
inordinate or spasmodic action, and a laceration 
of the uterus or other serious mischief might 
ensue. 

By allowing time, however, the rigidity would 
diminish, the parts would dilate (slowly and 
untowardly indeed for want of the mechanical, 
or wedge-like, action of the bag of waters); yet 
at length there would be so much of softness 
and dilatability, as to authorise the practitioner 
to proceed to the operation, which must be 
slowly and cautiously performed, as before 
described. 

4. Or it may happen that the waters have 
been early evacuated, the os uteri more or less 
dilated, the pains recurring often, and very 
strong and forcing. To attempt the turning 
under such circumstances would probably be 



115 

unavailing, and might be attended with great 
hazard to the mother. Here then nothing 
remains but to watch the patient attentively, 
and either to wait till the uterus having ex- 
hausted its strength in its fruitless endeavours 
to expel the child, becomes torpid, and incapa- 
ble of further exertion; or to lessen the vigour 
of the system by bleeding, or other depleting 
means, or to diminish the uterine action by a 
large dose of laudanum. This is the method 
recommended by Dr. Hamilton of Edinburgh, 
who speaks of it as attended with the most 
obvious good effects.* The dose that he gives 
is eighty drops. 

When from either of these plans the action 
©f the uterus becomes suspended, the earliest 



* " Select Cases in Midwifery^ ifc. By James Hamii- 
(Qn,jun. MD." p. 102. 1795. 

P 



114 

opportunity is to be taken of proceeding to 
deliver. 

I am well aware that some practitioners object 
to delay in either of these last cases, upon the 
following grounds. 

First, They say that where the child is thus 
placed and there are strong pains, much danger 
is incurred of rupturing the uterus; for that 
frequently this accident happens from the head 
or one of the limbs of the child forming a pro- 
tuberance, against which the uterus is so forcibly 
pressed, that at length its fibres give way, and a 
laceration ensues. Now it is contended that the 
danger of this occurrence can be prevented by 
one method only, viz. changing the posture of 
the child, which must therefore be effected at all 
hazards. 

That the danger of a rupture of the uterus 
under such circumstances is very great, I shall 



115 

not attempt to deny; but how will it be dimi- 
nished by the means proposed? Will there be 
less hazard in the efforts of the operator to push 
forward his hand in opposition to the powerful 
resistance of the uterus? Nay, is not the attempt 
to introduce the hand likely to excite the uterus 
to still more inordinate action, and consequently 
to increase rather than to diminish the danger? 
— I doubt not that an appeal to facts will prove, 
that the danger of a rupture is at least as great 
from the persevering attempts of the operator, 
as from the untoward position of the child. 

Secondly. It is argued, that if the uterus be 
not ruptured by its own powerful action, yet 
that the labour pains will by degrees force the 
arm, shoulder, breast, and perhaps the head of 
the child so firmly into the pelvis, as to render 
it impossible to pass the hand into the uterus, 
after the pains become suspended.* 

* Dr. Hamilton^ in his " Select Cases" gives an in- 



116 

In the practice of midwifery, as in other 
branches of the art of healing, we have some- 
times only a choice of difficulties, and much 
must of necessity be left to the discretion and 
judgment of the practitioner in each individual 
case that he attends. I am not disposed to think 
■ lightly of the hazard that attends having the 
fetus, thus preternaturally presenting, wedged 
into the pelvis; yet I am strongly inclined to 
believe, that there is less danger in this, than in 
forcing the hand into the rigid, unyielding 
uterus, in a state of active contraction. Upon 
the whole, therefore, I am of opinion, that there 
is a greater probability of doing good by delay, 
than in persisting to introduce the hand, when 
the uterus opposes so obstinate a resistance. 

I have not attempted to lay down any rules 



stance of this, and has subjoined some very judicious 
remarks upon the subject. 



117 

for the position of the patient while the operator 
is endeavouring to turn the child; because that 
position which gives him the most free use of 
his hand and arm is to be preferred, and under 
some circumstances one position, under others 
a different position, will be found most conve- 
nient. I generally make the attempt first, with 
my patient lying in the usual way on her left 
side, very near the edge of the bed, and use my 
light hand. Sometimes I have found, that while 
she was thus placed, I have been able to operate 
best with my left hand; or if I have preferred 
using my right hand,' I have been obliged to 
place my patient on her right side. Some prac- 
titioners very much recommend, that the patient 
shall be placed on her elbows and knees, and I 
have occasionally adopted this posture with ad- 
vantage, Smellie was an advocate for placing 
the woman on her back, with the breech raised 
higher than her shoulders, but I am not aware 
that any particular advantage results from this 
position during the operation of turning; but 



118 

when the body of the child is brought into the 
world, I have sometimes thought, that I have 
facilitated the passage of the head through the 
pelvis, by placing my patient on her back. 

It would be wrong to finish this chapter upon 
arm -presentations, without adverting to a curi- 
ous phenomenon, first accurately noticed by 
Dr. Denman, and since by other authors. It 
has occasionally happened, in these presenta- 
tions, that the labour pains have had the effect 
of forcing the nates or feet so low into the pelvis, 
that they have been precipitated through the 
os externum, and thus the turning of the child 
has been produced without the interference of 
the operator. In one or two such cases, the 
children have even been born alive. This has 
been called " the spontaneous evolution" of 
the child. * 



* See Denman's Midwifery^ p. 446. 



119 

The knowledge of this curious fact may, 
under some circumstances of extreme resist- 
ance to the passage of the hand into the uterus, 
reconcile us to the delay which I have above 
recommended; but we should never allow it to 
operate upon our minds, so as to induce us to 
neglect the proper means and proper time of 
turning when we have it in our power. 

4. Of presentations of the back, belly, or 
sides (d). 

Each of these presentations is stated in the 
report from the Maison d' Accouchemens to have 
occurred once in 5,833 labours. 

Dr. Bland takes no notice, in his " Calcula- 
tions of Accidents, &c. in consequence of 
Parturition," of these presentations. 

Dr. Denman says, " I do not mention the 
marks by which back, belly, or sides, might be 



120 

distinguished, because these, properly speak- 
ing, never constitute the presenting part; that is, 
though they may sometimes be feit, they never 
advance foremost into the pelvis, in the com- 
mencement, at least, of a labour." 

Introduction to Midwifery, p. 423. 

In the practice of my uncle Dr. Merriman, 
and in my own practice, amounting together to 
very near 20,000 labours, no instance has 
occurred of either of these presentations except 
in one or two cases where the mother had not 
completed her seventh month of utero- gestation, 
and in these the children passed doubled through 
the pelvis. 

I have however been informed of a very 
skilful practitioner in the country who has twice 
met with a presentation of the back. 

In such a case it is probable that in the 
course of the labour the presentation would be 



121 

changed for that of the nates. If no alteration 
in the position took place spontaneously, the 
introduction of the hand would be necessary to 
bring down the feet. 

5. Of presentations of the funis umbili- 
calis (e). 



Preternatural Labour. Order 6. Burns. 
Dystocia a Secundinis elapsis. Sauvages, § 8. 



This kind of presentation appears to have 
been much misunderstood formerly. It was 
supposed, when the funis came through the 
os uteri into the vagina, or without the os ex- 
ternum, that the child lay across the pelvis, the 
belly being over the os uteri; and this is the 
representation of the position given in Smellie's 
plates. This however is seldom or never the 
case. When the funis presents, there will be 



122 

found beyond it, either the head, the nates, or 
one of the extremities. 

This is always a case of difficulty, not on 
account of danger to the mother, but because 
there is a great probability of losing the child. 

Attention must be paid to the pulsation in 
the funis. If no pulsation is to be felt, the child 
is already dead; and the case is to be managed 
precisely as if the navel string were not pro- 
lapsed.* 

Should there however be a pulsation, we arc 
assured that the child is yet alive; and it becomes 



* The death of the child in prolapsion of the funis has 
been attributed to a congelation of the blood, from ex- 
posure to cold; but it is beyond a doubt, that its death is 
always occasioned, by compression of the funis between 
the child and the parts of the mother. It is to remove 
the funis from the effects of this compression that the 
assistance of the accoucheur is required. f- 



123 

us to consider in what way we can best proceed 
so as to preserve its life. 

Three expedients for this purpose have been 
recommended. 

First, To let the labour advance till the head 
of the child is within reach of the forceps, and 
then to hasten the delivery by means of this 
instrument. 

Secondly, To remove the navel string out of 
the way of compression. 

Thirdly, To hasten delivery by turning the 
child and bringing it by the feet. 

The first method probably possesses but little 
advantage beyond what may be gained by trust. 
ing the case entirely to nature. In some rare 
instances, where the mother has had children 
before, where the pelvis is very wide, the fetus 



124 

small, and the pains, strong and quick, the child 
has passed alive without extraordinary assist- 
ance. But the probability of this being effected 
is so remote, that it would be wrong to trust to 
it, did any other means of affording assistance 
present themselves. Should it however be found 
impossible to remove the funis out of the way 
of compression, or should the child's head have 
sunk too low into the. cavity of the pelvis, or 
should any other circumstance be present so as 
to render it hazardous to attempt turning, the 
application of the forceps might be admissible 
as the only remaining resource. 

The second method would be the most 
eligible could it always be put in practice; but 
the means of effecting a reduction of the pro- 
lapsed funis are not very easy. 

It has been proposed to carry it upon the 
points of the fingers, or upon a forked piece of 
cane or whalebone, through the os uteri, and 



above the bead of the child, so as to pre rem 
the funis from being pressed upon, as the head 
descends through the pelvis. But this expedient 
has been often found to fail; for upon withdraw, 
ing the fingers, or the forked stick, the funis 
nsuallv qnfc<i again into the vagina. 

Dr. Mackenzie once succeeded, by drawing 
without the os externum as much of die pro- 
lapsed funis as he could bring down, and in- 
closed the whole in a small bag, which was 
slightly tied at the neck. This he passed into 
the uterus beyond die child's head, where it 
was retained, and the child was born alive. 
This method seems deserving of farther trials, 
but Dr. Mackenzie never succeeded in it but 
once.* 

Dr. Croft has related two cases in which 



* DobhA Mtmfi) f j v.: z. 559, 



126 

he succeeded by carrying the prolapsed funis 
through the os uteri, and suspending it over one 
of the legs of the child. In both these cases the 
children were born alive.* 

Mr. Hogben has succeeded by introducing 
a piece of sponge into the uterus by means of 
a hollow tube with a piston affixed to it, some- 
what in the manner of a syringe for injecting 
fluids into the uterus; but he has had only one 
opportunity of trying this experiment.! 

Mr. Hopkins likewise speaks of the advan- 
tage of sponge in keeping up the prolapsed funis. 
The patient being placed upon her back, with 
her breech raised higher than her head, the 
operator must pass his hand into the vagina, 
raise the head of the fetus, and return the funis; 



* London MedicalJournal t vol. vii. p. 38. 1786. 
f Hegben's Obstetric Studies, 4to. p. 62. 1813. 



127 

after which he must introduce " a piece of new 
sponge shaped as the case requires, first wetted 
in warm water and squeezed as dry as possible: 
as the sponge swells, it prevents the funis from 
re-entering into the cavity of the pelvis, till the 
head is got below it.* 

Any of the foregoing methods that appear 
practicable in particular cases, may be attempt- 
ed; but there is reason to fear that they will 
frequently fail. 

The third method proposed, viz. the hasten- 
ing of the delivery by turning the child in utero, 
and bringing it by the feet, can only be resorted 
to under certain favourable circumstances. It is 
to be recollected that no possible advantage can 
accrue to the mother by turning the child; it is 



* Hofikin&'s Accoucheur's Vade Mecum^ p. 193. 



128 

the benefit of the child alone that we have in 
view. In case then of a want of pulsation in the 
navel string, which is a certain indication of the 
child's death, turning ought on no account to 
be attempted. Or should there be any circum- 
stances in the case, rendering it very improbable 
that the child could be preserved even if it were 
turned, it would be injudicious practice to 
attempt the operation. For as turning the child 
in utero is an operation always more or less 
hazardous to the mother, it is not justifiable to 
put her to this hazard, unless there be a well- 
grounded expectation of saving the child. If 
however there should be a tolerable probability 
of effecting this desirable object by turning, the 
mother ought not to refuse to risk something in 
favour of her infant. 

What has been said hitherto, applies chiefly 
to the presentation of the funis along with the 
head: when it presents together with any other 
part, the accoucheur will be guided in his prac- 



129 

(ice by the peculiarities of the case. If the arm 
and funis should present together, turning must 
of course be had recourse to, for this operation 
will then become necessary, not because the 
funis presents, but because the arm has sunk 
into the vagina. 



130 



Order 8. Dystocia Gemma — Labour of Twin 
(or more) Children. 



Anomalous Labour. Order 3. Denman. 
Preternatural Labour. Order 7. Burns 
Dystocia Geminorum. Young's Nosology 



It is seldom possible to ascertain that there 
are twins, till after the birth of the first child. 
Yet sometimes it is known during the first 
labour, by the membranes of each child being 
felt at the same time in the vagina; and some- 
times different parts of the two children come 
down together. 

Each of the twins is commonly smaller than 
a single child: this often occasions the birth to 



151 



be rapid, and gives to the practitioner the firs' 
idea that he is attending a case of twins. 



At other times, though it is evident to the 
touch that the child is small, and that there is 
plenty of room for it to pass, yet the pains, 
though frequent, do not propel it; hence the 
attendant is led to suspect, that the uterine 
action is impeded or interrupted by another 
child occupying the fundus uteri. 

Whenever there are good reasons for suspect- 
ing twins, it becomes the duty of the accoucheur 
fully to satisfy himself upon this point, before 
he quits the lying-in chamber. Generally, he 
may do this by laying his hand upon the abdo- 
men, or introducing a finger or two into the 
vagina; but rather than to remain in doubt, he 
had better pass the whole hand.* 



• The author must mean, that this is to be done aftei 



132 

Much diversity of opinion has prevailed 
among practitioners of midwifery, respecting 
the best method of managing twin cases: but 
this difference exists only with regard to the 
second labour; for the first requires to be con- 
ducted precisely as if it w r ere a single child. 

Thus, if the fetus presents naturally, the case 
is to be left to nature, as in Eutocia; if it 
presents preternaturally, or if any other circum- 
stances occur, constituting difficult labour, it 
will require the kind of management directed 
in the various orders of Dysto-cia: should, 
however, the case be of such a kind, as makes 
turning necessary, the operator must take care 
not to mistake the parts of the two children, 
lest he bring down a limb of each, and add 
greatly to the embarrassment of the case. 



the delivery of the first child, to ascertain whether or no 
there is a second. 



133 

But after the birth of the first child, the 
question to be resolved, is, whether the birth 
of the second shall be left to nature, or termi- 
nated by art? 

It is very well known, that repeated instances 
have happened, where the second child has 
been retained many hours or days* after the 
birth of the first, and no mischief, nor danger, 
ncr much of inconvenience has followed. Hence 
some have concluded rather hastily, that the 
birth of the second may always be safely trusted 
to nature, and that the interference of art is very 
seldom, if ever, necessarv. 



* In the Medical and Physical Journal for April, 1811, 
vol. xxv. p. 31 1, a case of twins is related, in which the 
second child was retained for fourteen days after the 
birth of the first; and the author of that communication 
states that another case had come to his knowledge, in 
which six weeks had elapsed between the births of the 
twins. 



134 

Others have alleged that very dangerous, 
and not unfrequently, fatal consequences have 
arisen, from allowing the second child to be 
long retained after the first is born: these have 
therefore argued, that it is always proper to 
accelerate by art the birth of the second child* 



Others, again, steer a middle course, and 
teach us to wait a moderate or reasonable time 
before we interfere by art to effect the second 
delivery; and it seems to be the opinion of some 
authors of great reputation and judgment, tiiat 
about four hours is the proper time to wait. 

It will hardly be denied, that some time ought 
to be allowed to recruit the woman's strength, 
and to give an opportunity for the second labour 
to come on spontaneously; but there will often 
be a difficulty in determining what space of time 
is to be considered as reasonable. There are, I 
imagine) many cases, in which it would be un- 
advisable to wait so long as four hours, before 



135 

the birth of the second child is artificially ex- 
cited; as, 

1st. Where circumstances have made it 
necessary to employ artificial aid in bringing 
the first child into the world. 

2dly. Where the second child presents in a 
preternatural position. 

3dly. Where convulsions, or haemorrhage, oi 
any other accident has occurred in the interval 
between the two labours. 

In either of these events, no doubt can, I 
imagine, be entertained of the expediency of 
finishing the labour long before the expiration 
of four hours. 

And even when the first labour has been 
favourable, and the second child is in a proper 
position, it may be doubted whether any ad van- 



136 

tage is likely to accrue from letting it remain 
four hours before an attempt is made to facilitate 
the delivery. In general, indeed, under these 
favourable circumstances, the secondary pains 
come on shortly after the first birth, and expel 
the child; but should this not happen, it may 
be prudent to excite them by rupturing the 
membranes in a much shorter space of time 
than four hours: it has seemed to me, upon 
various occasions, when so long a period as this 
has been permitted to elapse, that the pains of 
the second labour have been more severe, than 
they would have been had the action of the 
uterus been earlier excited. 

I should be very unwilling to appear the 
advocate of precipitation in any part of the 
practice of midwifery; but it has so happened, 
that I have known more than one instance of 
mischief, arising frpm the delay of bringing the 
second twin into the world, and therefore think 
myself justifiable in recommending an opposite 



137 

mode of conduct, though somewhat different 
from that which other practical accoucheurs 
have taught. 

The following is an outline of the practice 
which I have been in the habit of adopting in 
dystocia gemina: — 

1. When both the children present naturally, 
and the labour of the first terminates without 
artificial assistance, and without much fatigue 
to the patient, I wait for the spontaneous oc- 
currence of the secondary pains; but should 
these not come on soon, or in a reasonable 
time,* I rupture the membranes, and then 



* Much objection has been made to the terms reason- 
able or moderate^ because they are indefinite: but this is, 
in fact, one of the advantages of using these words. The 
proper time must always be determined by the attend- 
ing practitioner, according to the circumstances of the 
case. The reasonable time will frequently be less than 



138 

commonly find, that the second child passes 
with comparative ease through the pelvis, the 
parts having already undergone sufficient dila- 
tation. 

2. If the first labour has been natural, and 
the second child presents in a wrong direction, 
I have generally deemed it expedient, with very 
little delay, to extract it by the feet. 

3. If the first labour has been preternatural, 
or very difficult, or dangerous, this has always 
seemed to me an additional reason for termi- 
nating the second as expeditiously as circum- 
stances will admit. Whether in this case it will 
be sufficient merely to rupture the membranes, 
or whether it may be preferable to bring down 



half an hour; sometimes one or two hours; occasionally, 
perhaps, four hours. 



139 

the feet, or to assist in any other manner, the 
accoucheur in attendance must determine. 

It is an established rule not to acquaint the 
mother that there are twins, till both are born; 
for as it is known, that sudden emotions of the 
mind have been productive of ill consequences 
during labour, so it has been thought that some 
chief or inconvenience might ensue from the 
apprehension with which she might contem- 
plate the second labour. But though it is proper 
to conceal this circumstance from the mother, 
if possible, yet it is right to acquaint the hus- 
band, or some friend of the patient, of the real 
nature of the case, as soon as it is c 
known to the practitioner. 

*** The rules which are applicable to 
twin cases, will equally apply to cases 
where there are three or more children. 

*%* It very* commonly happens in dy$- 



140 

tocia gemina, that the labour occurs before 
the full term of nine months. 

A greater number of twin children, on an 
average, die during infancy, than of single chil- 
dren; and this remark applies still more strongly 
to triplets. 

X*X There seems to be a very extraor- 
dinary variety in the averages of twin and 
triplet births, in different countries, and 
under different circumstances. Thus it has 
been estimated, that the average of twin 
births has been — 



At the British Lying-in Hospital 1 iu 91. 

At the Westminster Dispensary 1 in 80. 

At the Dublin Lying-in Hospital 1 in 62. 

At the Middlesex Hospital 1 in 93. 

At the Maison d'Accouchemens at Paris 1 in 91.* 



* In the lying-in ward of the Philadelphia Aims- 
House, as appears from a regular Record kept for five 
years ending May 23, 1813, one woman only, in about 
107, had twins. — Ed. 



141 

In Germany twins are supposed to occur 
about once in 65 or 70 labours. 

Mr. Bums states the average in his practice 
at once in 95 labours. 

Respecting triplets, the averages are still less 
to be depended upon: many accoucheurs, of 
very extensive practice, have passed through a 
long life, without once witnessing three children 
at a birth. 

In the first 18,300 women delivered at the 
British Lying-in Hospital, not a single instance 
of triplets had occurred: but there were two 
such cases among 17,308 women delivered at 
the Maison d'Accouchemens at Paris, and three 
among 21,000 women at the Dublin Lying-in 
Hospital. 

Dr. Bland kept a very exact register of 1897 
women delivered at the expense of the West- 



142 

minster General Dispensary, among which there 
was one case of triplets: since I have held the 
office of physician-accoucheur to that charity, 
about 2500 women have been delivered; among 
whom I have twice been called to triplet 
labours. 

The averages of four children at a birth, are 
still less capable of being ascertained, yet seve- 
ral such instances are known to have happened; 
and there are a few authentic histories of five 
at a birth: Borcllus asserts, that about three 
years before he published his second Century 
of Observations, the wife of a nobleman in 
Languedoc was delivered of eight at a birth !!!* 



* Anno 1650: Uxornobilis D. Darre unico puerperio 
octo foetus enixa est probe conibrmatos, quod valde in his 
regionibus insolens est: tres enim tantum vitales simul 
enixos videram. 



143 



Order 9. Dystocia Laceratoria — Labour pro- 
ducing, or accompanied with, a Rupture or 
Laceration of some internal or external Part* 



Dystocia Laceratoria. Young's Nosology. 
Complicated Labour. Orders 2, 3, 6. Burns, 



Lacerations may take place from the violence 
of the labour pains; from improper exertions, 
or restlessness on the part of the patient; from 
mismanagement on the part of the practitioner; 
and sometimes from causes beyond our cogni- 
zance. This order may be divided into five 
species: viz. 



144 

a. Laceration of the perinaeum. 

b. of the labia pudendi. 

c. of the vagina or uterus. 

d. of any other internal organ. 

e. ■ — of the ligaments of the pelvis. 

1. Laceration of the perinaeum (a), though 
seldom dangerous, is always a very uncomfor- 
table accident, and when it extends so far as 
to divide the septum between the vagina and 
rectum, and thus to lay both passages into 
one, is to the last degree distressing ; for the 
unhappy patient has then no power of retaining 
her fasces, and of course becomes for ever after- 
wards an object of disgust, both to herself, and 
to all those who are obliged to associate with 
her. 

It would perhaps be asserting too much to 
say, that this kind of laceration may always be 
avoided; but unquestionably the practitioner 



145 

ought, in general, to be able to prevent so 
unfortunate an accident. 

The danger of a laceration of the perineum 
is greater in first, than in subsequent labours; 
but instances have been met with, where the 
laceration has happened to women who have 
borne several children before. The danger is 
always increased, when the head comes into 
the world in a wrong direction, as in dystocia 
perversa. 

The means of preventing a laceration are, 

1. Carefully to abstain from hurrying the 
head through the os externum. 

2. To avoid irritating the vagina and inner 
membrane of the perineum, and to 
guard against removing the mucous dis- 
charge naturally secreted for moistening 
the passage. 



146 

3. Occasionally to introduce lard or tallow, 
to moisten and soften these parts, when 
they feel dry and harsh, or heated.* 

4. To keep the hand covered by a soft 
napkin against the perinaeum, so as to 
afford a regular and equal support to the 
parts during the passage of the head* 

The cure of a lacerated perinaeum is very 
difficult, in some cases impossible. If, indeed, 
the rent does not extend through the sphincter 
ani, the torn parts will sometimes coalesce, so 
as to form a tolerable perinaeum; but when the 
laceration passes quite into the rectum, a cure 
is rarely perfected. 



* Injections of mucilaginous fluids into the vagina, as 
recommended by some French accoucheurs, would 
probably be efficacious. 



147 

It is of importance to keep the parts as ntu 
as possible in contact, which gives the best 
chance of their uniting; for this purpose it has 
sometimes been the practice to bring the edges 
of the wound together, bv suture; but this has 
seldom, if ever, been attended with good effects; 
on the contrary, the ligatures have been found 
to slough away, and the patient has in conse- 
quence been left in a worse condition than 
before. This mode of practice is therefore dis- 
continued. 

I have lately seen a case of perineal laceration, 
in which the surgeon, who was called in by the 
midwife, took great pains to promote adhesion, 
carefully drawing the edges of the wound to- 
gether by means of adhesive plaster, (emplas- 
trum resina) but his endeavours were unsuc- 
cessful; indeed, I believe that this plaster, by 
producing suppuration, was injurious, and the 
patient would have had a better chance of doing 

D, had the case been left to nature. 



148 

Would it be possible, at a more remote period 
after delivery, the edges of the torn parts being 
healed, and the patient being free from that 
irritable and feverish habit which generally 
accompanies the state of child-bed, — would it 
be possible under such circumstances to effect 
a cure by an operation upon these parts, similar 
to that for the hare lip? 

% Slight lacerations of the labia pudendi now 
and then take place; but seldom require any 
other treatment than the application of a soft 
poultice, a cooling wash, or simple ointment: 
this is a painful, but not usually a dangerous 
accident. It is sometimes produced by an ex- 
tensive tumefaction of the labia, occasioned by 
an effusion of blood into the cellular substance. 

3. I class lacerations of the vagina and uterus 
(c) together, because there is so great an ana- 
logy between the cases, and because both these 
parts frequently participate in the same injury; 



J 49 

for the place at which the rent happens, is com- 
monly at or near the union of the cervix uteri 
and the vagina, and the laceration extends to 
both parts. Sometimes, however, only the 
uterus, sometimes only the vagina, suffers. 

This accident has happened from a morbid 
state of the uterus, before the period of utero- 
gestation has been completed, and the fetus 
having escaped into the cavity of the abdomen, 
forms what has been denominated an extra- 
uterine conception of the ventral kind. Some- 
times the laceration appears to have been pro- 
duced from the untoward situation of the uterus 
in the pelvis: hence ulceration has taken place, 
and the fetus has been transferred into the cavity 
of the pelvis, and finally discharged through the 
vagina or rectum, in a dissolved and putrid 
state.* 



* Consult " Bartholinus de imolitis humani Partus 



150 

But more commonly the rupture is occasion- 
ed during labour, from the violence of the pains 
acting irregularly or impetuously against some 
projecting part of the child, upon which the 
uterus splits; and this is most likely to happen 
in cases of distorted pelvis, or of preternatural 
presentation of the child. Or it may be occa- 
sioned by the rude and forcible attempts of the 
operator to turn the child in utero; or by incon- 
siderate and violent endeavours to introduce 
instruments: and sometimes the immense bulk 
of an emphysematous child, in passing through 
the os uteri and vagina, has forced these parts 
asunder. 



Viis:" " Garthshore on Rujitures of the Uterus:" and 
« A Dissertation on the Retroversion of the Womb; in- 
cluding Observations on extra-uterine Gestation." 

[See also a case by Dr. M. Anthony, where Rupture 
of the Uterus was occasioned by a schirrous state of a 
portion of that viscus. Eclectic Repertory) vol. 4. p. 496. 
—Ed.] 



151 

If the rupture of the uterus has taken place 
before the full term of gestation is accomplished, 
and while the os uteri is undilated, it is obvi- 
ously impossible to afford the patient any kind 
of manual assistance; the case must therefore be 
trusted to nature, and under such circumstances, 
some women have wonderfully recovered; the 
child, in a dissolved state, having in a few in- 
stances, after months or years, made its way 
through the parietes of the abdomen by the 
process of ulceration. The operation of gastro- 
tomy has been recommended to give nature an 
earlier opportunity of getting rid of the burthen, 
but the success of such an operation is doubtful. 

When a laceration happens during the pains 
of labour, the following symptoms usually 
occur: viz. — 

a sense of something giving way internally; 
preceded by a very severe pain, gene- 
rally described as a cramp; 



152 

a sensation of great languor and debility; 

a speedy, sometimes an instantaneous vo- 
miting of the contents of the stomach; 

a vomiting of a brownish, or coffee-colour- 
ed fluid; 

a very quick, weak, fluttering pulse; 

a cold sweat; 

great difficulty of breathing; 

an immediate cessation of the labour pains. 

If now the patient is examined per vaginam, 
it will generally be found that the presenting 
part of the child, which had before been pressed 
some way into the pelvis, is retracted, and no 
longer within the reach of the finger; and if 
the hand is carried through the os externum, in 
order to make a more accurate examination, the 
child will be discovered to have passed either 
wholly or in part through a rent, into the cavity 
of the abdomen. There are, however, a few 



153 

instances in which the child has remained in 
utero, notwithstanding the laceration. 

The mode of practice recommended by 
many authors, in these unfortunate cases, is 
to give the patient a chance of recovery, by 
introducing the hand through the rent till it 
reaches the feet of the child, wheresoever they 
are to be found, and extracting the child foot- 
ling. In a few instances this plan has succeeded 
in saving the patient's life, but much more 
commonly all that is done proves unavailing, 
and death speedily ensues. 

The practice here recommended was coun- 
tenanced by Dr. Denman in his " Introduction 
to Midwifery," but circumstances have since 
that time induced him to reconsider this case 
more particularly, and after much inquiry and 
reflection he seems to be convinced that upon 
many occasions the patient would have a better 
chance of recovering if the case were resigned 

u 



154 

to the natural efforts of the constitution, than by 
any operation or interposition of art.* 

I must believe that either of these plans is to 
be preferred according to circumstances. If in a 
case of this kind it should be found, that the 
child had only in part escaped into the cavity of 
the abdomen, I should consider that it was the 
best practice to bring down the feet, if they 
were within reach, or to deliver by means of 
the forceps, if the situation of the head allowed 
of the application of those instruments. And 
even if the child had been wholly forced through 
the rent, that it would be expedient to extract 
it by the feet provided there was a ready passage 
for the hand into the cavity of the abdomen, and 
the accident had not been of long duration;! 



* See his " Observations on the Rupture of the Ute- 
rus" &c. 8vo. 1810. 

t See a case illustrative of this, in the New-York 
Medical Repository, for 1804. Hexade 2d, vol. 1. — Ed. 



155 

but if some hours had elapsed after the parts 
had given way, or if there were a difficulty in 
passing the hand on account of the contraction 
of the uterus, it would then perhaps be more 
prudent to leave the event to nature. 

Occasionally a rupture or laceration of some 
part either contiguous to, or more distant from, 
the uterus, has happened during labour (d); 
thus the bladder has sometimes burst from 
over-distention. 

This can only happen from neglect on the 
part of the practitioner, who should be careful 
to introduce the catheter from time to time if 
the woman has not the power of voiding her 
urine.* 



* The accoucheur must not implicitly rely upon the 
reports of the patient or her attendants respecting the 
discharge of urine, for very often they mistake a clis- 



156 

Should the laceration allow the urine to 
escape into the cavity of the abdomen, there 
can of course be no expectation of a recovery: 
but sometimes the laceration has been at the 
cervix vesicae, opening into the vagina; this 
accident is not necessarily fatal; but the patient 
will ever afterwards remain in a most uncom- 
fortable state from a constant involuntary dis- 
charge of urine. 



charge of thin fluid from the vagina or uterus for urine. 
Very lately I was called to the patient of a midwife in 
lingering labour, and inquiring when she had last made 
water, was told that it ran from her with every pain, so 
as to keep her continually wet. Not being satisfied with 
this report, I laid my hand upon the abdomen below the 
navel, and very distinctly felt the bladder considerably 
distended, and on passing the catheter drew off two 
quarts and half a pint of very high-coloured urine. This 
accumulation in the bladder had prevented the full effect 
of the labour-pains, and consequently rendered the pro- 
cess of parturition much longer than it otherwise would 
have been. 



157 

Sometimes the aorta, or other large blood 
vessel, has given way;* sometimes the liver has 
been ruptured; t and others of the viscera have 
experienced the same accident. 

5. When great numbness in the lower ex- 
tremities continues for a considerable time after 
delivery, with inconvenience and difficulty in 
moving the thighs, and pain and tenderness 
about the groins or hips, it may be supposed 
that a laceration of the ligaments of the pelvis 
has happened in a slight degree. More rarely a 
greater degree of laceration befalls these parts, 



* A case of rupture of the internal iliac vein, in the 
ninth month of pregnancy, is related in the 6th number 
of M The London Medical Repository" The author con- 
ceals his name, but the case has every other mark of 
authenticity. 

t See Memoirs of the Medical Society of London, vol. 
iii. 



158 



for sometimes the bones of the pelvis are forci- 
bly separated, producing a state of lameness 
and weakness which months and years very 
imperfectly overcome. 



159 



Order 8. Dystocia Hemorrhagica — Labour 
attended with Hemorrhage. 



Anomalous Labour. Order I. Denman, 
Complicated Labour. Order 2. Burns. 
Dystocia Hemorrhagica. Young. 



A discharge of blood from the uterus during 
pregnancy is frequently followed by abortion or 
premature labour; but careful management will 
sometimes prevent this accident. The plan to 
be adopted, is, to take away blood from the 
arm, if the pulse is full and strong; to remove 
costiveness by saline aperients; to employ, as 
the symptoms may indicate, refrigerants, seda- 
tives, and restringents; to enjoin quietude and 
a recumbent posture; and where the degree of 



160 

hemorrhage is considerable, to have recourse to 
the topical application of cold. 

If a flooding occurs just before, or during 
the process of parturition, the life of the patient 
will often be placed in great danger, and the 
child will frequently be dead born. Sometimes 
profuse hemorrhage follows the birth of the child 
or the expulsion of the placenta, and renders 
the situation of the patient very hazardous. 

Of Hemorrhage during Labour, 

The hemorrhages that occur during labour 
are occasioned by a separation more or less 
complete of the placenta, and the danger very 
much depends upon the position of the placenta 
in the uterus.* If the placenta be properly situ- 



* Labour is sometimes preceded by a sanguineous dis- 
charge or shew more than usually profuse, which may 



161 

atrd towards the fundus, the separation may 
produce alarming hemorrhage, but does not 



If the plarmf a has originally been placed over 
the cervix uteri, the danger is much more im- 
this forms the second species (b). 



Of the Treatment of the first Species of Dysto- 
cia Hemorrhagica; when the Placenta is 
r%iflg| t&mssedm At tMenm. 

The placenta thus situated is liable to be 
sqma l rd by various da jd rrts especially by 




162 

a blow or fall, by overstraining in the act of 
lifting any heavy burthen, by a violent cough, 
a sudden spasm, &c. The separation of the 
placenta from either of these causes may be 
partial only or entire, and in proportion as more 
or less is separated will be the danger of the 
case. 

It may happen that the degree of hemorrhage 
is much greater than appears externally; for 
blood may be poured into the space between the 
uterus and the placenta sufficient to produce 
syncope, or even death, and yet there may be 
very little appearance of discharge from the 
vagina.* 



* The following extract from the AVw Medical and 
Physical Journal shows not only the possibility of this 
fact, but likewise, that sometimes the loss of a quantity 
of blood by no means excessive will produce fatal con- 
sequences: " A very singular case of uterine hemor- 
" rhage occurred a few months ago in the practice of 



163 



_ : _ : ". r.t't :..:_.! : t z : "... ~ .t .: i*. 

ing to subdue k bj the 

The patient should be pbced in a 

rosce. "■.:." i ■• -rry ..:r.~." M'-tr.rr. ".~.r .: 



rf. . . . .'.. ... 



oUhy«f 

Tzt jct i 

:.-— - :: — 

v e : ■= : : - • 

a kvd of oaf «Se «nr„ aMo 



i : y : : : . t: ; ,-: - : - : • 



164 

cloths dipped in cold vinegar and water should 
be applied over the abdomen and pubcs, and if 
necessary, ice should be dissolved in the mix- 
ture to make it colder, or pounded ice itself, 
put into a bag, may be laid upon the belly. 

If the patient is costive, a pint of cold water, 
either by itself, or mixed with salt or a few 
spoonfuls of vinegar, may be thrown up the 
rectum; this often succeeds in producing a 
stool, and it is otherwise useful as a refrigerant 
applied to parts contiguous to the uterus. 

The diluted sulphuric acid may be given 
freely, either in rose infusion, mint water, 
weak cinnamon water, or any other convenient 
liquid* 



* The acetate of Lead is also worthy of a trial, in 
doses from two to four grains, combined with from one 
quarter to half a grain of opium, and repeated according 
to circumstances. — Ed, 



165 

I place but little reliance upon the other 
vegetable and mineral astringents; for though 
efficacious in cases of chronic uterine hemor- 
rhages, their astringent virtues are not suffi- 
ciently active in the sudden and violent hemor- 
rhages which accompany the separation of the 
placenta during labour. 

Bleeding from the arm has been recom- 
mended, and was formerly practised in these 
cases, with a view of making a revulsion from 
the uterus; and in many cases of fioodings 
during pregnancy ', where there is a hard, strong, 
full pulse, may be advantageously employed; 
but where the flooding accompanies labour, I 
consider blood-letting as likely to prove much 
more injurious than beneficial. 

Fortunately in many cases of sudden and 
accidental separation of the placenta, a disposi- 
tion to expel its contents is immediately im- 
parted to the uterus, and the expulsion is 



166 

facilitated by the relaxation which the heritor^ 
rhage has produced. The action of the uterus 
tends likewise to suppress the hemorrhage; If 
therefore pains come on, if the flooding in con- 
sequence diminishes, and if the patient in some 
measure recovers her strength and spirits, it 
may not be necessary to have recourse to any 
further means of relief; but the patient must 
still be very carefully watched, for the hemor- 
rhage may suddenly increase, and a very little 
additional loss of blood may prove fatal. 

But should the means employed to suppress 
the hemorrhage prove unavailing, should no 
pains come on, or should they be insufficient 
to restrain the flooding, and the danger of the 
patient augments, something more must be 
attempted. 

Till the time of Ambrose Pare no determi- 
nate practice in such cases was established; but 
we are told by his pupil, Guillemeauj that Pare 



1G7 

taught to turn and deliver by the feet in all dan- 
gerous floodings, and he relates several histories 
in his own practice of the success of this me- 
thod, and other histories, where, because this 
plan was not timely adopted, the patients were 
lost.* 

After Guillemeau, Mauriceau and his suc- 
cessors pursued this method, and found it to be 
frequently successful in preserving the life of 
the mother, if not of the child. Another plan 
however was proposed by M. Puzos, a very 
distinguished accoucheur at Paris, who died in 
1753: this method is less violent than that of 
introducing the hand and turning the child, yet 



* This method of treating flooding cases was practised 
by the celebrated midwife, Louisa Bourgeois-, and she 
has been supposed to be the author of it. Indeed, from 
a passage in her work, it might be thought that she 
claimed the merit of it; but I believe that we are indebt- 
ed for it to Pare, 



168 

in this species of hemorrhage is not less success- 
ful; it consists in piercing the membranes, and 
evacuating the waters, as soon as a disposition 
to labour comes on; thus the uterus is allowed 
to contract more completely, which diminishes 
or stops the flooding, and commonly in a few 
hours afterwards, the child is expelled by the 
natural pains. 

It has been objected to this method, that it 
cannot always be depended upon for suppress- 
ing the hemorrhage; and it is contended, that 
if this fails, the patient will be placed in a worse 
condition than before; because, should it at last 
become necessary to turn the child, the opera- 
tion of introducing the hand and bringing down 
the feet, will be rendered much more difficult, 
in consequence of the evacuation of the waters. 

I am not prepared to deny the validity of this 
objection under particular circumstances; yet I 
believe that the plan of piercing the membranes 



169 

in this species of hemorrhage, will so often suc- 
ceed, that we are justified in having recourse to 
it. Mr. Rigby, in his very valuable " Essay on 
Uterine Hemorrhage, &c." has detailed up- 
wards of 60 cases of this kind of flooding, in 
many of which this method was tried, and was 
completely successful; and in my own more 
limited practice, I have hitherto followed this 
plan, without a single instance of failure.* 



Of the Treatment of the second Species of 
Dystocia Hemorrhagica; when the Placenta 
is attached over the Cervix Uteri. 

This species of hemorrhage was not generally 
understood till of late years; when upon ex- 
amining per vaginam, the placenta was found 



* The Editor can also unite his testimony, from ex- 
perience, in favour of this plan of proceeding. — Ed. 



170 

presenting; it was supposed, that having been 
accidentally separated from the fundus, it had 
fallen by its own weight to the os uteri, which 
it closed up, so as to prevent the child from 
passing. More accurate observations and dis- 
sections have proved, that when the placenta 
presents, it has been ab origine implanted over 
the cervix uteri. Portal* seems to have enter- 
tained more correct opinions upon this subject 
than his contemporaries, but he did not fully 
understand it. 

This species of labour is more dangerous 
than the former. In the first kind, the coming 
on of labour pains has the effect of checking at 
least, if not of stopping the hemorrhage; but in 
this, as every pain tends to produce more dila- 
tation of the os uteri, and consequently a greater 



* Who lived about 1650. 



171 

separation of the placenta and an increase of the 
hemorrhage, so it is not prudent to trust to the 
pains for effecting the delivery. In all cases 
then of attachment of the placenta over the 
os uteri, it is incumbent upon the accoucheur 
to make up his mind to the operation of turning 
the child, and bringing it into the world by the. 
feet. 

There are indeed some cases of women who 
have not required this operation; for notwith- 
standing the presentation of the placenta, and 
the profuse hemorrhage, strong uterine action 
has been excited, the placenta and fetus have 
been expelled, and the patient has had strength 
enough to bear the flooding without undergoing 
any very imminent danger. 

It has likewise sometimes happened, that a 
small portion only of the placenta has been over 
the os uteri, and that the hemorrhage fas 
in consequence been comparatively trifling. 



172 

These cases have terminated without artificial 
aid, or with only the assistance of rupturing the 
membranes. 

But either of these are confessedly rare occur- 
rences, and we are not justified in taking rare 
or extreme cases as rules for practice. Here 
and there women do well without the inter- 
ference of art, but much more commonly, 
nature is unequal to the task, and the patient 
w r ould be lost for want of timely assistance; 
so that all the best practical writers are unani- 
mous on this point, that the case of a placenta 
adhering over the cervix uteri, is not to be 
trusted to nature. 

Though it has been thus decided, that the 
proper method of practice is to deliver by turn- 
ing the child, yet it sometimes requires much 
judgment and discrimination to determine when 
this is to be effected. If indeed the hemorrhage 
is profuse, and the os uteri in a state of dilata- 



173 

tion, there can be no doubt of the necessity of 
proceeding immediately to the operation, for a 
very short delay may be sufficient to prevent 
the success which is expected. 

But sometimes the hemorrhage may not be 
so violent as to create any great hazard, or the 
os uteri may be so thick and rigid as tp prevent 
the introduction of the hand, and this is by no 
means unusual when the hemorrhage begins as 
early as the sixth or seventh month of preg- 
nancy; in such cases it is necessary to wait till 
the os uteri becomes more soft and dilatable, 
which will happen in a longer or shorter time 
according to circumstances,* and the usual 



* Once more let me remark, that in all cases of uterine 
hemorrhage during fire gnancy, the patient ought to be 
very sedulously watched by her accoucheur. It may not 
indeed be possible or necessary for him to wait by the 
side of the patient during the whole continuance of the 
flooding, but he should take care to be in the way in 



174 

means for suppressing or diminishing hemor- 
rhage must in the mean time be employed. 

It is scarcely possible to lay down an exact 
rule, respecting the period at which the opera- 
tion of turning shall be undertaken; much must 
necessarily be left to the practitioner's judg- 
ment. In order that the performance of the 
operation shall be as little perplexing as possible 
to the practitioner, and as little hazardous to 
the mother, it is necessary that there be a cer- 
tain degree of softness and dilatability in the 
uterus; but this dilatability is not always to be 
judged of by the actual dilatation or openness 



case of a sudden alarm, and should give exact directions 
to some intelligent nurse or attendant how to act in his 
absence. A sudden gush of blood from a woman previ- 
ously reduced, may very shortly prove fatal. We ought 
not therefore to consider any woman subject to flooding 
as safe, particularly if the placenta be over the os uteri, 
till she is delivered. 



175 

of the part; for sometimes in hemorrhages the 
os uteri will be very dilatable, very capable of 
being dilated by art, though it hardly seems 
sufficiently open to admit a single finger. If 
under such circumstances we were to wait till 
the os uteri became so much open as to oppose 
no resistance whatever to the passage of the 
hand, it is probable that the operation would be 
performed too late to save the patient. If how- 
ever the accoucheur duly considers the case in 
all its bearings, the quantity of blood lost, the 
strength or weakness of his patient, and the 
actual softness or dilatability of the parts, he will 
hardly fall into an error, particularly if he recol- 
lects, that it is better to operate rather too soon, 
than to delay it too long; for the danger to the 
patient does not in general arise from the opera- 
tion of turning, but from the quantity of blood 
lost; it is therefore our duty, by timely perform- 
ing the operation, to prevent such a profuse 
loss of blood as shall put the patient's life in 
hazard. 



176 

Respecting the method of effecting the turn- 
ing, it does not differ much from the same 
operation under other circumstances. The 
entrance of the hand into the uterus will be 
opposed by the placenta adhering over the 
os internum, unless it be a section only of the 
placenta, which has been there implanted. 
Should this last be the case, there will be no 
difficulty in passing the hand by the placenta, 
rupturing the membranes, and turning the child. 
But if the whole of the os internum is closed 
up by the after-birth adhering to the cervix, the 
operator must either perforate the placenta with 
his fingers and hand, and thus get in contact 
with the body of the child, or he must break 
down the adhesion between the placenta and 
eervix uteri, till he reaches the membranes, 
which he must rupture, and proceed in the usual 
manner to turn the child. 

Of the advantages of these two methods of 
proceeding, different practitioners think differ* 



177 

end v. It has appeared to me, that if the mem- 
branes can easily be reached, it is preferable to 
carry the hand into the uterus by rupturing 
them, rather than to perforate the placenta; but 
I have sometimes been compelled to have 
recourse to the one, sometimes to the other 
method. 

It still remains to speak of a third species of 
hemorrhage (c), viz. that which occurs after 
the birth of the child. In this, all the usual 
means of suppressing hemorrhage are to be 
diligently employed. If the placenta is still re- 
tained, the hand must be introduced to separate 
it, for while it remains in utero, it acts as an 
extraneous body preventing the proper contrac- 
tion of that viscus, on which contraction alone, 
the power of stopping the flooding depends. 
Should the placenta be expelled, and the hemor- 
rhage be inordinate, in addition to the usual 
means of subduing it, pressure must be made 
upon the uterine region by means of the hands, 
2 



178 

or a broad bandage put round the body, and a 
sponge soaked in cold vinegar and water, or a 
lump of ice may be introduced into the vagina. 
Some writers strongly recommend to plug up 
the vagina with tow, lint, a handkerchief, or 
other proper substance, but I have never seen 
any decided good effects from the plug; on the 
contrary, have had reason more than once to 
think that it has been prejudicial. 

Sometimes large coagula collect in the uterus, 
and prevent its contraction: these are then to be 
considered as extraneous bodies acting like the 
retained placenta, and must in like manner be 
removed by introducing the hand. 



179 



Order 11. Dystocia Syncopalis — Labour accom- 
panied with Faintmgs, a Sense of Distress 
and Oppression about the Prcecordia, and 
Palpitations, 



Complicated Labour. Class 7. Order 3. Burns. 
Dystocia Syncopalis. Young. 
Hysteria a Partu difficili. Sauvages. 



In women of a delicate frame, of a nervous, 
irritable, hysterical habit, faintings during labour 
sometimes take place. 

They likewise occasionally happen to women 
exhausted by fatigue, by want of proper food, 



180 

by want of sleep, by apprehension, or any other 
debilitating cause, among which may very pro- 
perly be mentioned, the noisy conversation of 
many attendants in the lying- in- chamber, bad 
smells, and want of ventilation. These faintings 
partake generally of the nature of hysterical 
paroxyms; and have been sometimes mistaken 
for the true puerperal convulsions. 

More dangerous faintings may happen to 
women who have laboured under disease during 
their pregnancies, especially if they have had 
pulmonary complaints or organic diseases. 

Syncope, also, always attends profuse he- 
morrhage. 

The method of obviating this unpleasant 
symptom, is to give light cordials to women of 
delicate nervous habits, as camphor julep, sal. 
volatile, sp. setheris sulph. The room should 
be kept cool; volatiles or vinegar should be held 



181 

to the nostrils; and the forehead and temples 
may be advantageously washed with cold vine- 
gar and water. 

If the faintings arise from great fatigue or 
want of sleep, opiates may in addition be had 
recourse to; if from want of food — and this is 
not an unusual thing among the poor women 
who are delivered at their own habitations, at 
the expense of hospitals and dispensaries — beef 
tea, panado, or some wine or spirits in a little 
gruel, are required. If brought on by the heat 
and closeness of the room and the presence of 
too many attendants, these must be dismissed, 
and the room be ventilated and cooled. 

If the woman has been labouring under any 
severe disease during her pregnancy, and this 
gives the disposition to faintness, the above 
means may still be resorted to; but should the 
fainting be of long continuance, or be frequently 
repeated, it would probably be necessary to 



182 

hasten the delivery by any safe method in our 
power. And the same may be said of that 
fainting which sometimes occurs in conse- 
quence of the exhausted state of the patient 
from a long and difficult labour. 



19; 



Order 12. Dystocia Cojwulsiva — Labour 
accompanied with Convulsions* 



Complicated Labour. Order 4. Burns. 

CONVULSIONS DURING LABOUR. WattS. 

Dystocia Coxvulsiya. Young, § 10. 
Ecclampsia Parturientium. Sauvages. Class 4. 
Order 18. § 3. 



This is a very dangerous kind of labour, 
and has been so considered by all writers and 
practitioners. 

Dr. Hunter, Dr. Lowder, and other teachers 
of midwifery, used to state in their lectures that 
more than half of the women died who were 
attacked with convulsions in their labours, but 



184 

so great a proportion of deaths does not now 
happen. 

It is probable that hysterical paroxysms have 
sometimes been mistaken for the true puerpe- 
ral convulsions; at least if we may judge from 
the rapid cures that have been said to be made 
by, as it seems, very inadequate means. 

The cases alone deserving the appellation of 
puerperal convulsions, which have fallen under 
my observation, have borne a very exact resem- 
blance to the epilepsy, and this accords with the 
description of the complaint by the best authors 
on midwifery. 

The patient, sometimes before any signs of 
commencing labour have appeared, sometimes 
with the first pains, at other times not till the 
labour has made considerable progress, or even 
after the birth of the child, is attacked with a 
strong convulsion. The face is violently con- 



185 

tortcd, every muscle of the body becomes rigid, 
and a rattling in the throat is heard: this is fol- 
lowed by a sudden relaxation of the muscles, 
the limbs become convulsed, foam, generally 
tinged with blood from biting the tongue, issues 
from the mouth, " a sharp hissing noise" is 
produced by breathing through the fixed teeth 
and the foam, the eyes work about in a shock- 
ing manner, and altogether the patient presents 
a most horrid spectacle. 

This state of convulsion lasts for an indefi- 
nite time, then gradually ceases, and the patient 
sinks into a sleep, or rather stupor, during 
which the breathing is stertorous. 

In about half an hour or more, if there be no 
return of the paroxysm, she slowly recovers her 
recollection; complains then of great pain in the 
head, and of soreness in all her limbs; there is a 
heaviness in her countenance, a different tone in 
her voice, and a kind of insensibility or stupidity 

2 A 



186 

which leads the attendants to be apprehensive 
of a return of the fit. And this apprehension is 
generally well founded, for however complete 
the intermission may be, there is in almost 
every instance a repetition of the attack. 

Sometimes there is no return even to this 
imperfect recollection: before the first paroxysm 
is completely over, another comes on, and thus 
one fit follows another for many hours or days 
without any perfect intermission.* 

It has been remarked, that the more perfect 
the return to sense between the fits, the more 
probability is there of a favourable termination 
to the complaint; and this, I believe, is gene- 
rally true; but I have known patients ultimately 



* It was first remarked to me by Dr. Croft, and I have 
frequently observed it since, that an uncommon slow- 
ness of the pulse precedes each returning paroxysm. 



187 

recover who had no return of recollection in the 
intervals, and others to die where the intermis- 
sion was of long duration, and the return to 
sense unusually complete. 



Of the Causes and Method of treating Puer- 
peral Convulsions. 

There have been three causes in particular 
assigned as usually producing this disease: — 

1. General irritability of the constitution. 

2. Irritability of the uterus from distention. 

3. An overloaded state of the system. 

And practitioners have been influenced in 
their treatment of the complaint by the opinions 
they have entertained of its cause: thus those 
who have attributed the convulsions to general 
irritability, have considered opium as the proper 
remedy; those who have thought distention of 



188 

the uterus the cause, have recommended im- 
mediate delivery; those who believe an over- 
loaded state of the system to be the cause of 
the convulsions, employ large bleeding, and 
other evacuants. 

1. Of the use of opium I am not able to 
speak from experience; for I have never yet 
met with a case of puerperal convulsions, in 
which, at an early period of the disease, I could 
have dared to use this remedy. Dr. Hamilton 
says that he never saw a case where opium was 
given at the commencement, which did not ter- 
minate fatally. I am compelled therefore to 
believe, that, where opium has been beneficially 
employed, the disease differed in many respects 
from the true puerperal convulsions. 

2. My experience does not at all countenance 
the practice which some accoucheurs have 
adopted, of proceeding at once to terminate the 
labour, either by turning or by having recourse 



189 

to the perforator: yet, when the parts are pro- 
periy developed, the os uteri dilated, and the 
head of the child within reach of the forceps, it 
will probably be right to hasten the delivery by 
this instrument. But it will often be found, that 
a moderate delay in using instruments, will give 
a better chance of preserving the life of the 
child, without increasing the danger of the 
mother. 

3. Both theory and practice point out the pro- 
priety of adopting the third plan recommended. 
The symptoms indicate an overloaded state of 
the system. Prior to the attack of convulsions, 
there is often observed a flushed, or suffused 
countenance, violent pain in the head, vertigi- 
nous affections, drowsiness, heaviness in the 
eyes, temporary blindness, vacillation of mind, 
and slight delirium. Frequently, likewise, there 
will be the usual symptoms of indigestion, 
nausea, pain in the stomach and bowels, 
spasms, &c. 



In almost ;v_ ; that I have seen, the 

: nations from the bowels produced by 
cathartics have been dark coloured, he 
copious, arid ery fetid; and I do not recollect a 
single case in which the blood has not shown 
an inflammatory cms.; has often been 

T/ fas 'ill, I (. . authorize me 

to recommend, in the fi: ;ice, Iil 

urse to the depleting plan; :sA when the 
preci symptoms, above enumerated, begin 

to appear, the prudent practitioner will do well 
to bleed, and employ other evacuating remedies, 
before the convulsions actually take place. 

But if no means have been used to prevent 

the convulsions, the following plan should be 
adopted on their first occurrence, whether be- 
fore, during, or after the labour: — 

From ten to twenty ounces of blood, accord- 



191 

ing to the strength of the patient, and the state 
of her pulse, should be drawn from the arm, the 
jugular vein, or the temporal artery. 

If the patient is able to swallow, a pill con- 
taining five grains of calomel should be got 
down, and this should be followed by a solution 
of salts every three or four hours, till sufficient 
stools are procured. 

The head should be shaved, and a cold wash 
should be kept constantly applied upon it. 

The kind of lotion which I commonly pre- 
scribe is this: — 

g Liq. ammon. acet. 5 vi. 
Sp. rorismarin. = ij. 
Aq. purae, O i. 
M. ft. lotio. 

After giving the calomel pill, and more espe- 



192 

cially if the patient is incapable of swallowing, 
which is usually the case, a cathartic clyster 
should be injected, and repeated if necessary. 

These means will probably relieve the more 
urgent symptoms, and both the bleeding and 
the cathartics will tend to advance the labour, 
by producing relaxation about the vagina and 
uterus. The patient will have pains from time 
to time, and it will be necessary to examine 
occasionally what progress the labour makes. 

The convulsions will, however, return peri- 
odically; and it may, perhaps, be thought requi- 
site to take away more blood, the nece-sity of 
which will be determined by the appearance of 
that already drawn and the state of the pulse, 
and it may then be taken either by opening a 
vein, or by applying cupping glasses in the 
neck, [or to the forehead.] 

It will now be for the accoucheur to consider 



193 

whether it is any longer safe to leave the labour 
to nature: if it is proceeding quickly, as some- 
times happens, it will not, perhaps, be advisable 
to do any thing; yet I think if the pains are slow,* 
it is generally right, as soon as the child's head 
comes within reach of the forceps, to apply 
them, and finish the delivery without further 
delay. 

But if the danger to the mother should evi- 
dently increase, should she appear to be rapidly 
sinking, rather than that she should die unde- 
livered, it will be justifiable to have recourse to 
the perforator; yet I have so often had the plea- 
sure, by delaying this dreadful operation, of 
seeing my patient delivered of a living child, 



* Where the pains are slow, and it is desirable to ren- 
der them quicker and more efficacious, might not the 
Secale Cornutum be resorted to with some prospect of 
success?— Ed. 

2B 



194 

that I cannot too much insist upon caution and 
due deliberation upon this subject. 

It does not usually happen that the convul- 
sions cease upon the termination of the labour; 
on the contrary, they sometimes increase in vio- 
lence, and at length produce death. If, however, 
the intervals between the fits are longer, a more 
favourable prognosis may be formed; but it will 
be expedient to continue our exertions in re- 
lieving the symptoms. 

The application of the cold wash to the head 
should be persevered in: a blister may be ap- 
plied to the back, to the insides of the thighs, 
or calves of the legs: sinapisms may be applied 
to the feet: and if the patient can swallow, ape- 
rient medicines, antifebriles, and light cordials 
should be given. * 



Dr. Hamilton strongly recommends the use of cam- 



195 

Great attention must be paid to the state of 
the bladder, as the patient sometimes suffers 
under an inability of expelling her urine, in 
which case the catheter should be introduced 
twice a-day. 

When at length the patient recovers, she 
remains perfectly insensible of all that has hap- 
pened to her; her strength slowly returns, but 
eventually no trace remains of the disease; and 
there is not much danger of its recurring in a 
future labour. I have known two cases of mania 
occurring as soon as the convulsions ceased, 
and remaining for some time, but the patients 
ultimately got well. 



phor in puerperal convulsions, as the most powerful 
internal remedy — and Burns says, that where convul- 
sions have continued after delivery, or when the reco- 
very was not complete, he has found it of service. It is 
therefore certainly worthy of a trial. — Ep. 



196 

I have had few opportunities of examining 
wonfen after death who have died of convul- 
sions. Dr. Denman says, that he has never seen 
an instance of effusion of blood in the brain, 
though the vessels were extremely turgid: but 
has always remarked that the heart was unusual- 
ly flaccid, without a single drop in the auricles 
or ventricles; and the same has been noticed by 
other practitioners. In one case I have seen an 
effusion of blood in the posterior part of the 
cranium, but the quantity was not large. 

The plan of treating puerperal convulsions, 
here recommended, has been employed in 
twenty. two cases that I have attended, either in 
my own practice or in consultation. 

In 2 cases, the convulsions did not occur till after 
delivery: both these women recovered; the 
children were alive. 

In 2 cases the women being in labour of twins, the 
convulsions occurred in the interval between 
the birth of the two children, and the labours 
terminated without artificial assistance: one of 



197 

these women recovered; and three of the ch'il« 
dren were horn alive. 

In 5 cases, the delivery was effected hy the forceps: 
all these women recovered; and two of the 
children were born alive. 

In 4 cases, the perforator was used: three of these 
women recovered. 

In 2 cases, the children were turned: one of the 
women died; and both the children were dead 
born. 

In 7 cases, the children were born without extraor- 
dinary assistance: four of these women reco- 
vered; and four of the children were born 
alive. 

Thus 16 women recovered 11 children were horn alive. 
6 died 13 dead. 

In 18 instances it was the patient's first labour. 



198 



Order 13. Dystocia Inflammatoria — Labour 
accompanied with Local Lnflammation, or 
general Pyrexia. 



Dystocia Inflammatoria. Young, 



Fever or inflammation may accompany la- 
bour, either in consequence of a previous dis- 
ease being present when the patient goes into 
labour; or from improper management, or from 
some other cause after the labour has com- 
menced. 

Thus pneumonia, catarrhus, pleuritis, perito- 
nitis, variola, rubeola, scarlatina, typhus, &c. 



199 

may occur during pregnancy, and many of 
these complaints will probably bring on prema- 
ture labour, which commonly rather adds to, 
than diminishes, the hazard of the patient. 

The nature of the accompanying disease will 
in a great measure influence the treatment of 
these cases: the means of cure proper for the 
specific complaint must consequently be resort- 
ed to, modified, however, in some degree, by 
the state of pregnancy. 

If improper management has greatly in- 
creased the usual febrile state* of the process of 



* A degree of fever always accompanies labour, as 
may be known by the quick hurried pulse, the tendency 
to shivering, the thirst and loss of appetite for solid food; 
but as this is usual, it excites little attention, unless the 
fever rises to an immoderate height. The knowledge of 
this fact ought, however, to put practitioners on their 
guard, not to increase by stimulants the already excited 
system. 



200 

parturition, or if local inflammation has been 
excited either in the uterus or vagina, in the 
rectum producing piles, in the perineum, in 
the urethra, or elsewhere, it will be necessary 
to have recourse to some of the following means, 
viz. bleeding, aperients, clysters, antifebriles, 
washes, poultices, opiates, rest and quietude; 
and these means having been duly persevered 
in, the complaint will generally give way, and 
the labour will terminate safelv. 



201 



Order 14. Dystocia Retentiva. 

Young, CI. 5.O. 77. §7. 

Labour followed oy a Retention of the Placenta 
for more than an Hour after the Birth of the 
Child— See p. 10. 



The usual causes of a retained placenta, are, 

(a) a want of contraction in the uterus; 

(b) a partial or imperfect contraction; 

(c) a morbid adhesion of the placenta to 
the uterus. 

Very different opinions have existed among 
practitioners of midwifery respecting the ma- 
nagement of the placenta. 

2C 



202 

In the earliest ages, when parturition was a 
more natural process than it now is, the expul- 
sion of the placenta was probably always left to 
nature. 

When, however, it became customary, or 
necessary, to help women in labour, the assist- 
ance was often rudely, or improperly given, 
and thus the regular process of parturition was 
interrupted, and a necessity was produced of 
giving assistance to bring away the placenta. 

The means used were, for the midwife to 
twist the funis about her fingers, and to drag by 
that, till the placenta was brought away. This 
hasty, incautious, and dangerous proceeding, 
often occasioned the funis to be torn away from 
its attachment to the placenta, and not uncom- 
monly produced a total inversion of the uterus* 
Ruysch informs us, that he was twice in one day 
sent for to women, to whom this unfortunate 
accident had happened. 



203 

The frequency of these accidents afterwards 
led to the adoption of another method: this was 
to introduce the hand into the uterus as soon as 
the child was born, and at once to separate the 
placenta from it; and there were many practition- 
ers who supposed that this operation was always 
expedient, and uniformly practised it in every 
labour they attended. 

The late Dr. William Hunter, whose skill 
and judgment in the practice of midwifery w r ere 
much esteemed, having a very high opinion of 
the powers of nature to effect her own work, 
and probably being acquainted with many mis- 
chances, arising from the practice of thus intro- 
ducing the hand to separate the placenta, taught 
that the delivery of the placenta was always to 
be left to nature; and this plan he uniformly fol- 
lowed in his own practice, and recommended it 
strongly to his pupils and others. 

For a long time this method was successful; 



204 

the placenta was regularly expelled by the 
secondary pains, sometimes in an hour or two, 
sometimes not for twelve or twenty-four hours; 
and upon some occasions the placenta was re- 
tained even beyond this period, without any 
ill consequences supervening. But upon other 
occasions, the ill effects of not timely removing 
the placenta were apparent. In the practice of 
one of Dr. Hunter's pupils, a patient retained 
the placenta thirteen days; it was then expelled 
in a dreadful state of putrefaction, and the pa- 
tient expired the same day. Another woman 
retained the placenta eleven days, and died with- 
out at all expelling it; and among Dr. Hunter's 
own patients, two or three calamitous accidents 
took place, which led him, towards the latter 
end of his life, to alter the opinion he had formed 
of the propriety of always leaving this case to 
nature. 

Experience has now taught us that if the 
labour be perfectly natural, and if the operator 



205 

be not hasty to interfere with his assistance,* 
the expulsion of the placenta from the uterus, 
will generally be effected in ten, twenty, or 
thirty minutes after the birth of the child; all 
rfien that is required from the accoucheur, is 
to remove it from the vagina; and this he may 
always safely do, if he proceeds cautiously, as 
soon as it is thrown off from the uterus by the 
uterine action. 

If, however, the secondary pains do not take 
place within this period of time, it may be 
proper for the accoucheur to lay his hand upon 
the abdomen, and gently to rub the part where 



* The practice of using force to hurry the shoulders 
and body of the child through the os externum as soon 
as the head was born, is now very generally laid aside. 
There can be no doubt that this imprudent conduct 
often brought on a retention of the placenta. See 
White* 8 Treatise on the Management of Pregnant and 
Lying-in Women, where are recorded many cases of 
death occurring from retention of the placenta. 



206 

the uterus is to be felt, or to press it with his 
hand, provided the pressure be not so great as 
to occasion much uneasiness. By acting thus, 
he will frequently be sensible that a contraction 
of the uterus takes place; and will find, upon 
examination, that the placenta has fallen into 
the vagina, completely separated from the 
uterus. 

This seems all that it is right to do for a full 
hour after the child is born; but that time 
being elapsed, and there being no reason to 
expect that the uterine contractions will spon- 
taneously arise, the accoucheur is to consider 
whether it is prudent to wait longer before he 
proceeds to extract the placenta, by introducing 
his hand into the uterus. 

And if no bad symptoms are present, there 
can be no danger in allowing more time to 
elapse before w r e proceed to this operation, and 
more especially, if there is reason to think, that 



207 

the retention arises principally from the exhaust- 
ed state of the patient; because it is possible, 
that a little more delay will recruit her strength, 
and that afterwards sufficient power may be 
imparted to the uterus, to enable it to expel the 
placenta. 

Yet, generally speaking, we can have but 
little expectation that the placenta will be ex- 
pelled by the natural powers, after it has been 
retained for a full hour; we may, therefore, con- 
sider ourselves justified in interfering to extract 
it at the end of one hour after the child is born. 

It appears then to be a question of prudence 
or discretion, which every accoucheur must 
judge of, in the individual case he is attending-, 
whether to proceed to delivery at the end of the 
hour, or to wait another hour or two before he 
undertakes this operation. But of course this 
only applies to cases where there is no apparent 
danger; for in cases of profuse hemorrhage, &c; 



208 

there is no question upon the subject; here the 
delivery of the placenta is to be immediately 
undertaken without delay. 

The method of proceeding to extract the 
placenta is as follows: — the patient lying in the 
usual way on her left side, or upon her back, 
with the nates very near the edge of the bed, is 
to have the belly moderately pressed upon by 
an assistant; but the pressure ought not to be so 
great as to give much pain. The accoucheur 
then, having taken off his coat, and smeared his 
hand and arm with lard, is to take hold of the 
funis with his left hand, and to carry his right 
hand into the uterus, making the funis his 
guide. 

The irritation and pain which this will pro- 
duce, may possibly excite the action of the 
uterus, and the placenta be cast off; if so, the 
operation is speedily performed: and if this for- 
tunate event does not take place, it may be right 



209 

to endeavour to produce uterine action, by 
moving the fingers about slightly near the 
os uteri. 

If, notwithstanding, we fail to bring on uterine 
action, we must proceed to make an artificial 
separation; and therefore still making the funis 
©ur guide, we must pass the right hand on, till 
we reach the part where the funis is inserted; 
then, deliberately feeling for the edge of the pla- 
centa, we must cautiously insinuate our fingers 
between it and the uterus, and steadily pursuing 
•ur intention, must entirely separate it before 
we desist; and it is well to keep the hand in the 
uterus for a few moments, till a contraction 
comes on. 

Of the length of time that it will take to per* 
form this operation, it is impossible to speak 
with certainty. If no impediments should arise, 
the whole may be effected in a few minutes; but 
should there be an irregular contraction of the 

2 D 



210 

uterus, forming what has been called the hour- 
glass contraction; or should the os uteri have 
become contracted and rigid, it may take a very 
considerable time to dilate and overcome this 
impediment. 

This is one of the operations that is perform- 
ed more safely, if performed slowly; it is one in 
which, to use an expression of Dr. DenmarCs^ 
we should " let the head direct the hand." 

The average number of times that retention 
of the placenta may be expected, is very 
difficult to be ascertained. In well-conducted 
private practice, it rarely occurs except from a 
morbid state of the uterus or placenta. But 
accidental retentions of the placenta, from un- 
due, or irregular, or improper contraction of 
the uterus, very often take place, among inex- 
perienced or hasty practitioners, from misma- 
nagement. During a period of six years, that I 
have been physician-accoucheur to the West* 



211 

minster General Dispensary, I have been called 
to cases of retained placenta among the patients 
of that charity once in every 77 labours: in my 
private practice, retention of the placenta has 
not occurred oftener than once in 300 labours.* 



* In the cases (a) where the placenta is retained from 
«* a want of contraction in the Uterus," the Secale Cor- 
nutum promises to be a useful remedy: in the cases (b) 
of u partial or imperfect contraction," or in what has 
been called, the hour-glass contraction of the Uterus, its 
good effects may be considered as rather more problema- 
tical; yet I should, notwithstanding-, consider it as wortby 
of a trial.— Ed. 



212 



Order 15. Dystocia Inversoria — Labour foU 
lowed by Inversion of the Uterus. 

Young, § 11. 

Inversion of the uterus was formerly an acci- 
dent of frequent occurrence, but since a more 
judicious method of managing the delivery of 
the placenta has been adopted, it is compara- 
tively rare. 

Whenever this accident does happen, no time 
must be lost in re-placing the uterus, and espe- 
cial care must be taken to have it completely 
re-inverted^ 



* Inversion of the Uterus, for the purposes of prac- 
tice, may be divided into two species, viz. the complete 
and the fiartial. When complete, it protrudes out of the 



213 



Of the Use of Instruments in Midwifery. 

It becomes every man, who means to enter 
into the practice of midwifery, to set out with 
a determination, that he will not hastily, or 
without due cause, have recourse to instrumen- 
tal assistance; for he may assure himself, that 



vagina, and the os uteri is turned upwards, forming a 
communication with the cavity of the abdomen — the 
vagina in this case is partially inverted. In the partial 
inversion, the tumor is generally retained within the 
vagina, the fundus uteri only protruding to a certain 
degree through the os uteri. In this latter case, where 
it has been found impracticable to reduce the uterus, it 
has been advised to grasp the portion which has passed 
through the os uteri, and render the inversion complete, 
by bringing the whole of the uterus into the vagina, and 
keeping it there. By this means it is supposed, that the 
danger of strangulation from the constriction of the 
os uteri on the body of that viscus, is prevented. See a 
case related by Dr. Dewees, in the Philadelphia Medi- 
cal Museum, vol. 6. Burns's chapter on this subject, is 
vrell worthy of perusal. — Ep. 



2U 

if he were easily to yield to his own apprehen- 
sions, or to the expressions of alarm by the 
attendants in the lying-in chamber, and in con- 
sequence were to try to expedite the delivery 
by his instruments, he would, on very many 
occasions, do irreparable injury to the patient, 
or her child. 

Abundance of instances might be produced 
of women, who, from a hasty and improper use 
of instruments, have been placed in a state of 
the greatest possible danger, or have actually 
lost their lives, or have been left in a state of 
misery and suffering, worse than death itself. 
Nor can there be a doubt, that many children's 
lives have been sacrificed by premature inter- 
ference with instruments. Now, surely nothing 
ought to be more dreaded by every practitioner 
of midwifery, than the reflection, that a loss of 
life, or a life of continual distress and pain, has 
been occasioned either to the mother or the 
child, by his impatience or want of caution. 



215 

Yet, though it behoves us all to enteitain a 
just dread of the improper use of instruments, 
it likewise becomes us to be careful, that this 
dread of instruments is not carried too far; for 
as much mischief may be done by delaying 
instruments too long, as by using them too 
soon. 

The old adage, neque temere neque timide, 
though trite, is still a good motto for the 
accoucheur. Let us not be hasty in the use of 
instruments, so as to do injury by precipitancy; 
nor let us delay them too long, lest our patient 
be so much exhausted before they are applied, 
as to derive no benefit from the operation. 

When attending a case of lingering, difficult, 
or dangerous labour, it is our duty from time 
to time to consider, what probability there is 
of a favourable termination; and whether it 
is safe to leave it longer, and how much longer, 
to the efforts of nature. And in forming our 



216 

opinion, we may in a great measure be guided 
by the favourable or unfavourable symptoms* 
enumerated at page 50. As the favourable or 
unfavourable symptoms preponderate, we may 
safely draw our conclusions: but if we are not 
able to satisfy ourselves perfectly upon this mo- 
mentous point, it will be prudent to obtain the 
opinion of some of our medical brethren, that 
we may not incur the censure of having acted 
rashly.* 



* As consultations may sometimes be difficult to pro- 
cure in the country, where the necessity for prompt as- 
sistance may be peculiarly urgent, it is incumbent on 
every student and practitioner of Midwifery, to make 
himself well acquainted with the subjects treated of in 
the remainder of this work. The precepts are generally 
highly judicious, and appear to be founded on experi- 
ence, and the result of extensive and successful prac- 
tice. The Editor has, nevertheless, taken the liberty of 
dissenting from certain axioms of the author; for which 
reasons, that he hopes will appear satisfactory to the 
reader, are given. — Ed. 



217 

If, after having carefully considered and re- 
considered the case, it appears expedient ;o have 
recourse to instumental aid, we are then to 
determine upon the kind of instrument that is 
adapted to the case. 

The instruments used in midwifery are of 
three k.nds: — 

1. Those which do not of necessity injure 
either the mother or the child; 

viz. the fillet, 
the forceps, 
the lever.* 

2. Those which are intended to mutilate 
the infant, and the use of which is of 



* The blunt hook, may with propriety, be added te 
the above — Ed. 



218 

course incompatible with the life of the 
child; 

viz. the perforator, 
the blunt hook,* 
the crotchet. 

3. Those which are intended to inflict a 
wound upon the mother, as in the Cesa- 
rean operation, or the division of the 
symphysis pubis. 

Of the Fillet, the Forceps, and the Feet is. 

Modern practice has excluded the fillet, ex- 
cept in cases of preternatural presentations of 
the child. 



* The blunt hook, when properly applied, need not 
mutilate the infant; neither ought it to be considered as 
incompatible with the life of the child, when used with 
discretion.— Ed. 



219 

Of the merits of the forceps and vectis, dif- 
ferent writers and practitioners think very dif- 
ferently; some extol the advantages of the for- 
ceps, others of the lever; some consider the 
forceps as always safe, the lever as always dan- 
gerous; others assert that the lever is always 
equally safe, and contend that it possesses two 
great advantages over the forceps, because it 
can be applied with greater ease, and can be 
secretly introduced. 

After having made a very careful compara- 
tive examination of these two instruments, I 
have been led to draw the following conclu- 
sions: — 

1. That either instrument, in the hands of a 
cautious operator, and in proper cases, may be 
safely and advantageously used. 

2. That either instrument, improperly ap- 



220 

plied, is capable of producing very serious 
mischief. 

3. That cases sometimes occur, in which the 
forceps will effect the delivery better than the 
lever; and that, in other cases, the lever is 
capable of effecting the delivery, though the 
forceps are noi.* 



* il That the lever is ever capable of effecting the 
delivery, though the forceps are not/' is to me difficult 
to conceive — it is in fact asserting, that one blade of ihe 
forceps is capable of effecting what cannot be accom- 
plished by both — or, that one lever has greater power 
than two, in overcoming or removing an obstacle. The 
forceps may certainly be acted with as a lever of double 
power; to which may be added the force of traction, 
which the vectis cannot properly be said to possess. 

That the lever may be applied before the forceps can 
be acted with advantageously, is true; but in these cases, 
it is often improper to apply any instrument, until the 
head has descended lower in the pelvis. 

The chief, and indeed, almost the exclusive utility of 
the lever, appears to me to consist, in its application to 



221 

4. That as the lever is capable of being 
introduced more easily, and at an earlier period 
of the labour, much earlier indeed than the case 
requires or the rules of art allow, it is more 
frequently used unnecessarily, and of course 
hazardously, than the forceps. 

Lastly, I consider that what has been stated, 
as an advantage in the lever, viz. the practica- 
bility of using it secretly, is one of its worst 
properties. For I look upon it as a sacred duty, 
which an accoucheur owes to his patients as 
well as to himself, never to employ instruments 
secretly. He owes it to his patients, because 
there can be no security against the rash and 



cases of malposition of the head; and even in these 
cases, a single blade of the forceps may frequently sup- 
ply its place: and here, after rectifying the position, I 
would prefer the application of the second blade, so that 
the delivery of the head might be accomplished by the 
forceps.—- E». 



222 

improper use of instruments, unless the practi- 
tioner avows his intentions, and explains to the 
friends his reasons for employing them. He 
owes it to himself, because if the case requires 
the aid of instruments, he gains credit and re- 
putation for his proficiency and skill. 



Of the Cases that admit of the Application of 
the Forceps or Vectis. 

The cases that principally require the use of 
the forceps and vectis are those that belong — 

1. To the class dystocia anenergica, where 
the head having passed so low into the pelvis 
as to allow the ear of the child to be felt, is 
stopped in its progress, there being no pains, or 
not sufficient pains, to propel it.* 



* It is to this Class of Labours, after the soft parts are 
sufficiently dilated, that the Secale Cornutum seems 



To some instances of dystocia amorph 
where, though there may be deformity of the 
pelvis, it is not so great as to keep the ear of 
the child beyond the reach of the finger. 

5. To cases of dystocia commlsrva, &€• when 
the ear can be felt. 

No case is to be esteemed eligible for the 
application of either of these instruments, unless 
the ear of the child can be distinctly felt; by 
which time it is presumed that the cs often will 
be well dilated, and the perinaeum somewhat 
relaxed. 

So careful have the best professors of mid- 



piliinhil 2.dip:er. — and Ibe Editor caanol iroid^fiuB 
his own experience, recommending grring it a lair, bat 
discreet trial, before having recourse to the vectis or 
forceps, except when combined with the abore, malpo- 
sition of the head may be suspected to exist. — Ed. 



224 

wifeiy been to guard against an improper use 
of these instruments, that it has been laid down 
as a rule of practice, " That the forceps shall 
never be applied till the ear of the child has 
been within reach of the operator's finger, for 
at least six hours."* 

This is a judicious rule, and ought to be ge- 
nerally adhered to, since very few cases indeed 
occur (hemorrhage and convulsions excepted) 
in which it would be unsafe to wait for six 
hours after the ear comes within reach of the 
finger: nor should recourse be had to instru- 
ments even then, if a probable chance exists of 
finishing the labour safely without them. 

It is not necessary to give very minute direc- 
tions, in this place, respecting the manner of 



* During which period, the head is supposed not to 
have progressed, or in a very trifling degree.— Ej>. 



225 

applying the lever or forceps; but I shall make 
a few general remarks, premising, that it will 
be proper first to introduce a catheter into the 
bladder, in order that we may be sure it con- 
tains no urine, and to clear the rectum by 
throwing up a clyster. 

Having then placed the patient in the position 
most favourable for our purpose, which will 
commonly be on her left side, the nates being 
brought very near to the edge of the bed,* we 
are to pass the fore finger of the right hand to 
the child's ear: then taking the handle of the 
forceps in the left hand, we are to introduce the 
point of the blade into the vagina, and making 
the finger of the right hand our guide, are with 
great caution to carry forward the blade to the 



* These directions apply only to the short English 
forceps — the best form of which, is that which is now 
commonly termed here, Haighton's Forceps En. 

2F 



226 

child's ear, over which it is to be passed, and 
gently insinuated beyond it, till the claw of the 
forceps is brought quite to, or within the os 
externum. 

The first blade being thus applied, is to be 
kept in its place by the fourth and little lingers 
of the operator's left hand, while with his right 
hand he introduces the second blade of the 
forceps over the opposite ear of the child. 

But as he will not be able to feel the opposite 
ear, he must be guided in some measure, in 
introducing the second blade, by the position 
of the first. 

Both blades being introduced, the claws are 
to be brought together and locked, care being 
taken not to entangle any of the hair, or soft 
parts, in the lock.* 

* We should be particular in introducing the blades 



227 

If, on endeavouring to lock the forceps, it 
should be found that they do not readily come 
together, they have not been properly intro- 
duced: no force or violence, therefore, should 
be used to bring them together; but the second 
blade should be withdrawn, and introduced 
afresh. 

When the forceps are locked, if the handles 
are in contact with each other through their 
whole length, they are not properly applied; for 
the bulk of the head is usually too great to 
allow the handles to touch each other, if the 
head is properly included within the bows of 
the forceps. 

If the handles are very far apart, the points 



in the direction of the axis of the pelvis, which is to be 
considered as an imaginary line, drawn from the centre 
of the superior strait, to about the middle of the peri- 
naeum, — Ed. 



■2-28 

of the blades probably rest upon the ears; at all 
events, the head is not properly embraced by 
the forceps; and, in attempting to act with them, 
they will slip. 

When acting with the forceps, the force at 
first used should be ven moderate, but is to be 
increased as occasion may require: yet if the 
head advances at all, however slowly, with the 
force first applied, it need not be increased; for 
as Dr. Den man has ven- truly observed, " a 
small degree of force continued for a long time, 
will in general be equivalent to a greater force 
hastily exerted, and with infinitely less detriment 
either to moiher or child."* 



* In acting with the forceps, to prevent them from 
slipping, it is very necessary to act from handle to han- 
dle, through the whole process of extraction; but this, 
and other requisite rules, can only be satisfactorily ex- 
plained to the student, in their application on tne ma- 
chine. — Ed. 



2*29 



It is unnecessary to appear very adroit, or to 
yse great t xptdition in introducing the forceps: 
it is much better to introduce them slowly and 
. , than hastily and dangerous!] . 

The introduction and action n irh the lever, 
subjected to very much the same rules as 
those of the forceps. Equal care i=> to be taken 
not to be precipitate in having recourse to it, 
not to do mischief in introducing it, and not to 
bruise the mother, or otherwise to injure her. 
while acting with it. 



Of the Cases requiring the Use of the Perfo- 
rator. 

The cases which require the perforator are 
those, where the pelvis is so small at the brim : 
that the child's head cannot pass through it. 
Other causes do indeed sometimes render the 
perforator necessary; but the legitimate cause 



230 

for using this instrument, is distortion of the 
pelvis. 

Cases of distortion of the pelvis frequently 
occur, yet it is sometimes very difficult to as- 
certain whether the distortion is really so great 
as to prevent the head from passing through it 
undiminished; and under such circumstances it 
becomes us to be extremely careful not rashly 
to determine upon having recourse to the per- 
forator. 

Various means have been recommended for 
accurately measuring the dimensions of the 
pelvis; and the ingenuity of foreign accoucheurs 
has produced a number of different instruments, 
called pelvimeters, which are supposed to ascer- 
tain this point with great precision. 

But there is probably much more of inaccu- 
racy in this mode of admeasurement on the 
living body, than at first sight may appear; and 



231 

certainly the inferences drawn from such ad- 
measurements, and the modes of practice re- 
commended, are most grossly unscientific and 
perilous. 

Thus we are taught by Stein, Plenck, and 
others: — 

" 1. That if the straight or conjugate diame- 
ter of the pelvis amounts to four French inches,* 
the labour will be easy, and should be left to 
nature. 

"2, If this diameter amounts to 3| inches, 
the labour will be slow, but the child may be 
born alive:" they consider this as a fit case for 
the vectis. 



* The French inch is divided into twelve lines, and it 
measures about one line, or the twelfth of an inch more 
than the English. Four French inches, therefore, make 
rather more than four inches and a quarter English, 



232 

"3. If to 3§ inches, the child," they say, 
" will be dead if the case is left to nature; but 
it may be born alive if the forceps are applied 
in time. 

" 4. If only to 3 1 inches, the labour cannot 
be effected by the pains; and if the forceps are 
used, the child will be dead;" therefore they 
recommend to have " recourse to the division 
of the symphysis pubis, if the child be living; 
and to the perforator, if it be dead. 

" 5. If the conjugate diameter only amounts 
to 3 inches, 2|, 2§, 2 J inches, neither the 
natural pains, nor the forceps, will effect the 
delivery; therefore, if the child be living, the 
Cesarean operation is to be performed; if dead, 
the perforator is to be employed. 

" 6. If this diameter amounts only to 2 inches, 
it is probable," they say, " that even if the child 
be dead, the perforator cannot be used;" here 



233 

then they make no hesitation of recommending 
the Cesarean section if the child be alive. 

" 7. If the dimensions of the pelvis are as 
small as 1| or If inch, the child, whether living 
or dead, cannot pass, and the mother must 
undergo the Cesarean section." 

Even admitting that these admeasurements 
could be accurately ascertained, the practice 
recommended is, to say the least of it, hasty 
and injudicious; but many instances might be 
adduced of the inaccuracy of pelvimeters in 
ascertaining the dimensions of the pelvis. 

Dr. Osbcrn, who took great pains in investi- 
gating the best method of procedure in cases of 
distorted pelvis, considers that a fetus at full 
maturity cannot pass aiive, if the dimensions of 
the pelvis, from the pubes to the projection of 
the sacrum, be only 2| inches; but as it has 
been ascertained by Dr. Hamilton^ that children 

2G 



234 

have been born living, though the pelvis in this 
diameter was " manifestly under three inches;" 
it is necessary that practitioners of midwifery- 
should be very much upon their guard against 
being deceived in their estimate of the actual 
dimensions. 

In England [and also in the United States,] 
we are more in the habit of examining the size 
of the pelvis by our fingers, than by pelvime- 
ters; and though we are not able, with so much 
appearance of precision, to state the actual 
amount of inches and lines, yet perhaps we may 
judge equally well, whether the case can be 
terminated without the use of the perforator.* 



* " Although the sacrum may project so much, or 
advance into the pelvis so far, as to reach within two or 
three inches of the pubes. and consequently the entrance 
into that cavity would be only of that diameter, if the 
bones were directly opposite to each other; yet the 
pubes being placed something lower than the greatest 



235 

In many cases, however, it will be difficult 
to determine whether the distortion is so great, 
as to render the delivery of an entire child 
impossible; and if there is this difficulty, it be- 
comes us to wait, as long as the safety of the 
woman will admit, before we proceed to the 
operation of cephalotomia. In other cases the 



projection of the sacrum, and opposed to a par: of that 
bone that diverges backward, the real distance between 
them may be much more considerable than to the touch 
it may seem to be. Whence it happens, that in cases 
where the projection of the sacrum has occasioned ex- 
ceeding great difficulty in the beginning of the labour, 
opposing an almost insuperable bar to the entrance of 
the head of the child into the pelvis, by directing it too 
far over the pubes; yet when that direction has been 
altered by the crotchet, or by any other means, and the 
head brought into the line of the cemre of the pelvis, 
the conclusion of the labour has been frequently effect- 
ed with very little exertion or force." — B:z'.:.'i 0:i~r. 
vatioiu on Human and Co mfi a r mtivc Perturiiiz-^, p \ 
5th section. 

The whole of this section deserves the very attentive 
perusal of every practitioner of midwifery. 



236 

distortion will be so very considerable, as must 
satisfy us, upon the first examination, of the 
impossibility of effecting the birth without di- 
minishing the child;* but even in this case, a 
considerable space of time should be allowed 
to elapse before we proceed to the operation; 
and generally it will be right to have a consul- 
tation with some other accoucheur, before the 
perforator is employed, particularly if it be a 
first child; f 

1. Because the operation, by being delayed, 
will be more easily and safely performed. 



* These cases, as we have heretofore observed, are of 
extremely rare occurrence in natives of the United 
States. — Ed. 

t At the close of this volume, are added two plates of 
deformed pelvis, to illustrate the different directions in 
which the pelves may be contracted in its dimensions 
See PL IV. and V.— Ed, 



. :ause we shall have the comfort of 
knowing or belie \ing that we did not introduce 
the instrument while the child was yet livir 

Because it is our duty to let the patient 
and her friends be as well convinced of the 
necessity for the operation, as we are. Now 
ire form our judgment of the necessity, from 
examining the dimensions of the pelvis: they 
can only judge, from the undue length and 
severity of the labour, and even then may still 
require the sanction of a deliberate consultation. 

When it is at length determined upon to 
proceed to this operation, moderate caution 
will enable the operator to perform it without 
danger of injuring the mother. He must take 
care to have the os uteri sufficiendy dikfe-fl , 
and most let his finger be the guide to the point 
of the perforator, till it reaches the head of the 
child. After he has made an incision through 
the scalp, he must guard the instrument from 



238 

slipping till he has drilled through the cranium,* 
and enlarged the aperture, by drawing asunder 
the handles of the instrument. 

It will often be advantageous, after the per- 
foration is made, to allow some hours to elapse 
before an attempt is made to separate the bones 
of the cranium. But respecting the propriety of 
this, the practitioner must judge for himself, 
founding his opinion upon the state of the pa- 
tient and the length of time that the labour has 
already lasted. 



* It will be best, when practicable, which is often the 

case, to perforate at one of the fontaneiles or sutures 

Ed. 



259 



Of the Cesarean Operation. 

This operation has been so generally unsuc- 
cessful in England,- that we can have but little 
inducement to recommend it. 

It is supposed that the Cesarean operation is 
more successfully performed upon the continent 
than in this island, and it is certainly more 
frequently employed there. 

Since the year 1750 there have been about 
20 or 22 instances of this operation in England, 
and only two of the mothers recovered; nine of 
the children, however, were born alive. 

31. Baudelocgue, in his " Memoir upon the 



* This observation will, as I believe, also apply to the 
result of this operation in the United States — En. 



240 

Cesarean Operation," has collected accounts 
of 73 operations: thirty-one of the women re- 
covered, and twenty. seven of the children were 
born alive; but many of these operations were 
most rashly resolved upon, since it cannot be 
doubted, that some of the women would have 
been delivered with no more than the ordinary 
assistance, had the cases been left to nature; and 
others might have been delivered by art without 
having their lives placed in such imminent 
peril.* 



* It is impossible to read without horror of the shame- 
ful ignorance shown by some of the operators who per- 
formed and advised these operations. In many cases 
there was no distortion of the pelvis !!! in some, the body 
of the child was born, and the operation was performed 
to set the head at liberty! in one case the head was sunk 
so low in the pelvis, that when the abdomen and uterus 
were opened, and the body of the child brought through 
the wound, it required all the strength of a very power- 
ful man, standing on the bed, to drag at the body, while 
another was forcing the head back with his hand in the 
vagina, to get the child's head back through the superior 



241 

I cannot for a moment doubt, that wherever 
the perforator can be employed, it is a much 
safer mode of delivery for the mother, than the 
Cesarean section; yet I must admit, if any cre- 
dit is to be given to medical records, that cases 
have occasionally been met with, which pre- 
sented so great a distortion of the pelvis, as to 
preclude the possibility of using the perforator, 
and in which, of course, the only possible chance 
of saving either the mother or child, lay in this 
operation; but such instances are extremely 
rare. 



aperture or brim, beyond which it had passed into the 
cavity of the pelvis!!! 



2 H 



242 



On inducing Premature Labour, as a Means of 
preventing the JVecessity of having Recourse 
to the Perforator, 

As there is a paper of mine upon this subject, 
in the third volume of " The Medico- Chirur- 
gical Transactions,"* I shall not now enlarge 
upon it; but shall content myself with extract- 
ing, from that paper, the rules, limitations, and 
cautions, which ought, I think, to guide us in 
adopting this mode of practice. 

" 1. As the primary object is to preserve the 
life of the child, the operation should never be 
undertaken, till seven complete months of utero- 
gestation have elapsed; and if the pelvis of the 
mother be not too much contracted to allow of 



* See also a paper by the Editor. Eclectic Repertory, 
Vol. I. p. 105, et seq. — Ed. 



it, the delay of another fortnight will give a 
greater chance to the child of surviving the 
birth. 

" 2. The practice should never be adopted, 
till experience has decidedly proved, that the 
mother is incapable of bearing a full-grown 
fetus alive. 

" 3. It is sometimes necessary to have re- 
course to the perforator in a first labour, though 
there may be no considerable distortion of the 
pelvis; therefore the use of this instrument in a 
former labour is not alone to be considered as a 
justification of the practice. 

" 4. The operation ought not to be perform- 
ed when the patient is labouring under any 
dangerous disease. 

"5. If upon examination, before the opera- 
tion is performed, it should be discovered that 



244 

the presentation is preternatural, it might be 
advisable to defer it for a few days, as it is pos- 
sible that a spontaneous alteration of the child's 
position may take place; particularly if the pre- 
sentation be of the superior extremities. 

" 6. The utmost care should be taken to 
guard against an attack of shivering and fever, 
which seems to be no unusual consequence of 
this attempt to induce uterine action, and has 
often proved destructive to the child, as well as 
alarming with regard to the mother. The pecu- 
liar circumstances under which the operation is 
performed, and the habit of body of the patient, 
will determine the accoucheur either to adopt a 
strictly antiphlogistic plan, or to exhibit opiates, 
or antispasmodics and tonics. 

"7. In order to give every possible chance 
for preserving the life of the child, it will be 
prudent to have a wet nurse in readiness, that 



245 

the child may have a plentiful supply of breast- 
milk from the very hour of its birth. 

" Lastly, A regard to his own character 
should determine the accoucheur, not to perforin 
this operation unless some other respectable 
practitioner has seen the patient, and has 
acknowledged the operation as advisable" 



TABLES. 



Various tables have, upon different occasions, 
been published, of the accidents, extraordinary 
incidents, deaths, &c. that have occurred during 
labour; and it is probable that much benefit 
would result, and certainly some instruction 
would be gained, by correct statements of this 
kind. For some time past I have endeavoured 
to keep a very correct account of the kinds of 
labours that I have attended; and, since the 
commencement of my register, have delivered 
upwards of 1800 women. The result of these 
labours will be seen in the following table: the 
number, however, is not sufficiently great to 
draw very correct averages. It should be men- 
tioned, that this list does not include any patients 
of the charities to which I belong. 



£49 



In 1559 cases, the child presented' "^- 

75 or 1 in 24, though V'^a. 

20 or 1 in 90, the iovt\ vcrsa > a * 

4 or 1 in 450, the fac< > b - 

4 or 1 in 450, thenar > c - 

42 or I in 43, the nate:'^ r6a > a - 

23 or 1 in 78, the low< > b - 

7 or 1 in 257, the sup > c - 

8 or 1 in 225, the fun > € - 

1 or 1 in 1 800, the h? toria > a - 

22 or 1 in 82, the pati^ zwa » a - 

1 or 1 in 1800, the pa > b - 

1 or 1 in 1 800, the xfitoria^ c. 

1 or 1 in 1 800, a lar£- j d - 

8 or 1 in 225, the pla^ zVa > a * 

4 or 1 in 150, thepla > 6 - 

12 or 1 in 150, there a — ; — > c « 

2 or 1 in 900, there ^iva. 
6 or 1 in 300, the pla™'"^- 

In 12 cas 
In 7 cas 
9 of the a 
viz. 



20, or 1 i 
8, or 1 i 
5 ofth€ 



£49 
TABLE 

Of the Number of Accidents, Deaths, &c. in 1800 Labours. 

1800 labours produced 1813 children: viz. 929 boys, 884 girls. 

In 1559 cases, the child presented properly, and the labour was over in less than 24 hours, - constituting Eutocia 

75 or 1 in 24, though the children presented properly, the labour lasted more than 24 hours - Dystocia Diutina 

20 or 1 in 90, the forehead was turned towards the pubes --_--.. . Perversa 

4 or 1 in 450, the face presented --------.-_ 

4 or 1 in 450, the hand or arm came down with the head ....... ■ 



42 or 1 in 43, the nates or one hip presented ......... 7 

23 or 1 in 78, the lower extremities presented ----..... 

7 or 1 in 257, the superior extremities presented ........ 

8 or 1 in 225, the funis presented - .......... 

1 or 1 in 1800, the hymen was unruptured . . . -» Obturatoria, 

22 or 1 in 82, the patient was delivered of twins ........ q 

1 or 1 in 1800, the patient was delivered of triplets ........ _ 

1 or 1 in 1800, the uterus ruptured Laceratoria 

1 or 1 in 1 800, a large blood-vessel in the abdomen burst 



or 1 in 225, the placenta separated within the uterus Hemorrhagica 

4 or I in 150, the placenta was attached over the os uteri ....... 

12 or 1 in 1 50, there was flooding after delivery .- - - - • - - - 

2 or 1 in 900, there were convulsions during labour Convulsiva 

6 or 1 in 300, the placenta was preternaturally adhering - Rcten 

In 12 cases, or 1 in 15,0, the forceps or the lever were used.* 
In 7 cases, or 1 in 257, the perforator was ernployed.t 
9 of the above women, or 1 in 200, died in the month of child-bed: 
viz. 3 of puerperal fever. 

1 suddenly, on the 5th day after delivery, without any known cause. 

1 in convulsions, 18 hours after delivery. 

1 of phthisis pulmonalis, 12 hours after delivery. 

1 broke a blood-vessel in the abdomen, and soon expired undelivered. 

1 of rupture of the uterus. 

1 of peripneumonia notha. 

20, or 1 in 90, had, in a greater and slighter degree, peritonitis pucrperalis. 
8, or 1 in 225, had the oedema lacteum. 
5 of the children, or 1 in 363, had the rectum imperforate; 
the operation was performed on all; 

2 died in less than 3 days; 
1 lived 6 months; 

the other 2 are still alive— one six, the other three years old. 



* In 2 cases, on account of Dystocia Convulsiva. 

2 Perversa, a. 

8 Anencrgica- 

t In all these cases the pelvis was distorted. 
21 



250 








• 












TABLt 


As 


published by 


Madame Bo'win % 


onec 






(See her 


" Memon 


Number of children born 


- 12,751 












10,003, 












1,213, 


or 


1 in 


10 






4, 


or 


1 in 


3,188 






1) 


or 


I in 


12,751 






2, 


or 


1 in 


6,375 






1, 


or 


1 in 


12,751 






1, 


or 


1 in 


12,751 






40, 


or 


1 in 


319 






20 


or 


1 in 


638 






1, 


or 


1 in 


12,751 






22, 


or 


1 in 


579 






17, 


or 


1 in 


750 






181, 


or 


1 in 


70 






3, 


or 


1 in 


4,251 






6, 


or 


1 in 


2,125 








or 


1 in 


4,251 






3, 


or 


1 in 


4,251 






2, 


or 


1 in 


6,375 






85, 


or 


1 in 


150 






58, 


or 


1 in 


58 






2, 


or 


1 in 


4,251 






1, 


or 


1 in 


12,751 






3» 


or 


I in 


4,251 






3, 


or 


1 in 


4,251 






3, 


or 


1 in 


4,251 






20, 


or 


1 in 


637 






18, 


or 


1 in 


708 






2, 


or 


1 in 


6,375 


* Query, is this correct? Sratllie, in his plates 


, gives a delineatioi 



251 



Table of the Number of Accidents or Deaths 
which happen in consequence of Parturition; 
taken from the Midwifery Reports of the 
JVestminster General Dispensary. By Ro- 
bert Bland, M. D. 

Of 1897 women delivered under the care of 
the Dispensary, 

53 (or 1 in 30) had unnatural labours: in 

18 of these (or 1 in 105) the children present- 
ed by their feet; in 
36 (or 1 in 52) the breech presented; in 
8 the arms presented; and in £ 9* (or 1 in 
1 the funis. 



5210.) 



17 women (or 1 in 111) had laborious labours; 

in 
f8 of these (or 1 in 236) the heads of the chil- 
dren were lessened; in 

80 8 



* In all these nine cases the children were turned. 

]■ T«o of these women have since been delivered of full- sized 

2K 



250 



TABLE OF PRESENTATIONS; 
As published by Madame Boivin, one of the Superintendants of the Hospice de la Maternite, at Paris. 
(See her " Memorial de VArt des Accouchement 1812.) 



Number of children born 



12,751 

10,003, 
1,213, or 1 in 10 

4, or 1 in 3,188 
l,or 1 in 12,751 

2, or 1 in 6,375 
1, or 1 in 12,751 
l,or 1 in 12,751 

40, or 1 in 319 
20, or 1 in 638 

1, or 1 in 12,751 
22, or 1 in 579 
17, or 1 in 750 

181,orlin 70 

3, or 1 in 4,251 
6, or 1 in 2,125 
3, or 1 in 4,251 
3, or 1 in 4,25 1 

2, or 1 in 6,375 
85, or 1 in 150 
58, or 1 in 58 

2, or 1 in 4,251 

1, or 1 in 12,751 

3, or I in 4,251 
3, or 1 in 4,251 
3, or 1 in 4,25 1 

20, or 1 in 637 
18, or 1 in 708 

2, or 1 in 6,375 



Kind of Presentation. 

the vertex; occiput towards the left groin. 

the vertex; occiput towards the right groin. 

the vertex; occiput resting on the symphysis pubis. 

the occiput. 

the left side of the head. 

the right side of the head. 

the head and hand. 

the forehead to the left of the pubes. 

the forehead to the right of the pubes. 

the face, with the chin to the sacrum. 

the face, with the chin to the right side of the pelvis. 

the face, with the chin to the left side of the pelvis. 

the nates, with the face towards the right sacro-iliac synchondrosis, 

the nates, with the face towards the mother's back. 

the nates, with the face towards the mother's belly. 

the right hip. 

the loins. 

the back. 

the feet, the toes turned to the right of the pelvis. 

the feet, the toes turned to the left of the pelvis. 

the feet, the toes to the mother's back. 

the knees. 

the navel string and belly* 

the loins. 

the back. 

the right arm. 

the left arm. 

the right breast. 



• <** is thiscorrecU S.n.He, h his plat e„ *. a Nation of the same kind f P re 8 e n tatio n; but I never knew a single pMctitioner who had <Ter met with it . 



80 8 



252 



a single blade of a forceps was used; and in 
the remaining 

in which the faces of the children were 
turned to the pubes, the delivery was at 
length accomplished by the pains. 



17 



i woman had convulsions about the seventh 

month of her pregnancy, and was deliver- 
ed a month after of a dead child, and re- 
covered. 

1 woman had convulsions during labour, 

brought forth a live child, and recovered. 
*9 women (or 1 in 210) had uterine hemor- 

rhage before and during labour. 

Of these 1 died undelivered; 

1 died in a few hours, and 



91 



healthy children. A third bore a very small and weakly child, who 
died in two or three days. A fourth was delivered of a seven months* 
child, without mutilating it, which, died in its passage. The number of 
women, therefore, who from error in their conformation were incapa- 
ble of bearing live children, appears to be very inconsiderable. Of the 
remaining four I have not been able to get any intelligence. 

* In these nine cases, only one child was saved. 



253 

2 

1 ten days, after delivery; and 

6 recovered. 



5 women had the puerperal fever, of whom 

four died. In one of these the placenta 
was undelivered, and continued so to her 
death. 

2 wc>men were seized with mania, but reco- 

vered in about three months. In 

I woman a suppuration took place, soon after 

labour, from the vagina into the bladder 
and rectum. This patient recovered, but 
the urine and stools continue to pass 
through the wounds. Of 

1 woman the perinaeum was lacerated to the 

sphincter ani. A suture was attempted, 
but without effect; she recovered, but is 
troubled with prolapsus uteri. 

5 had large and painful swellings of the legs 

and thighs, but recovered. 

105 therefore of these (or 1 in 18) had preter- 

natural or laborious births, or suffered in 
consequence of labour. Of this number of 
cases 43 (or 1 in 44) were attended with 
particular difficulty or danger; and 7 only 
(or 1 in 270) died. The remaining 62 



105 



254 



were delivered and recovered with little 
more than the common assistance; and 
1792 had natural labours, not attended with any 

particular accidents. 



1897 



255 



Table of Presentations at the Maison 
dWccouchemens. 

There have been admitted into the Lying-in Hospital 
at Paris (Maison d'Accouchemens), between the 9th of 
Dec. 1799, and the 31st of May, 1809, 17,308 women, 
who gave birth to 17,499 children: 189 of them have 
been delivered of twins, and two only of three children. 
The proportion of twin cases to single births is I to 91. 

Two thousand of these women were affected after- 
wards with illness, or some serious accident; 700 died 
out of the 2000. 

Of the 17>499 births, 16,286 were presentations of 

the vertex to the cs- uteri. 



No. 




Proportions. 


215 were presentations of the feet 


- 


1 to 


81 ! 


296 the breech - 


- 


1 . — 


59$ 


59 the Lee - 


- 


1 — . 


296| 


52 one of the shoulders 


. 


1 — — 


336-1 


4 the side of the thorax 


. 


1 __ 


4374| 


4 the hip - 


- 


1 — 


4374^ 


4 the left side of the head 


. 


1 — — 


4374J 


4 the knees : 


- 


1 — 


4 374| 


4 the head, an arm, and the cord 


- 


1 


43741 


3 the belly .... 


- 


1 ... 


5833 


3 the back .... 


. 


1 


5833 


3 the loins .... 


- 


1 — . 


5833 



256 



I the occipital region - - - 1 — 17499 

I the side, with the right hand - 1 — 17499 

1 the right hand and left foot - - 1 — 17499 

1 the head and the feet - - - 1 — 17499 

2 the head, the hand, and forearm - 1 — 8749J 
37 the head and umbilical cord - 1 — 473 

Of this great number of women 230 were delivered 
by art; the rest were natural births, being in proportion 
of 1 to 76 J. 161 were delivered by the hand alone, the 
children heing brought by the feet; 49 were delivered by 
the forceps, either on account of the small dimensions 
of the pelvis, the falling down of the umbilical cord, or 
the wrong position of the head, when the woman was 
exhausted, or her life was in danger by convulsions, &c; 
13 were extracted by the crotchet after perforation of 
the head, on account of mal-conformation of the pelvis: 
in these instances, the death of the child was first ascer- 
tained. 

The Cesarian operation was performed in two cases, 
the diameter of the pelvis being only one inch six lines 
from sacrum to pubes. 

In one, the section of the symphysis pubis was per- 
formed, the diameter of the pelvis from sacrum to pubis 
being only two inches and a quarter. 

Gastrotomy was performed once, the fetus being 
extra-uterine: the child weighed 8lb. 2 oz. 



257 



Table of the average Number of Deaths in 
Child -bed in London , taken from the Bills of 
Mortality. 



4 


pears er 


iding 


in 1660 — 1 in 


36. 


10 


- 


- 


1670 


39. 


10 


- 


- 


1680 


49. 


10 


- 


- 


1690 


47. 


10 


- 


- 


1700 


65. 


10 


- 




1710 


67. 


10 


- 




1720 


72. 


10 


- 




1730 


73. 


10 


- 




1740 


70. 


10 


- 




1750 


74. 


10 


- 




1760 


81. 


10 


- 




1770 


72. 


10 


- 




1780 


92. 


10 


- 




1790 


107. 


10 


- 




1800 


113. 


10 


- 




1810 


106. 


3 


- 


- 


1813 


116. 



258 

Table of the average number of Deaths in 
Child-Bed in Philadelphia, taken from the 
Bills of Mortality. — Ed. 

The population of the city of Philadelphia and its 
suburbs, within the bills of mortality, may be estimated 
at 100,000. The average number of deaths in child- 
bed solely, and also in child-bed and puerperal fever 
jointly, taken from the said bills for nine years, is as 
follows:— 

For 1 year ending Jan. 2, 1808 — 1 in 170 1 in 107 

1 - - 1, 1809—1 in 567 I in 378 

.1 - - 1, 1810—1 in 2004 1 in 400* 

1 - - 1, 1811—1 in 2036 1 in I56f 

1 1, 1812—1 in 477 1 in 265 

1 - - 1, 1813—1 in 600 1 in 257 

1 - - 1, 1814—1 in 408 1 in 272 

1 - - 1, 1815—1 in 296 1 in 254$ 

1 - . 1, 1816—1 in 291 I in 204 

The average number of deaths in child-bed, exclu- 
sive of puerperal fever, for 9 years, is 1 in 418. 

The average number of deaths in child-bed, and 
puerperal fever jointly, for 9 years, is 1 in 219. 



* In this year, but 1 woman is stated to have died in parturition, and 
4 of puerperal fever — the total number of deaths being 2004. 

•\ In this year, but 1 woman is stated to have died in child-bed, and 
12 of puerperal fever — the total number of deaths being 2036. 

$ In this year, but 1 woman Is stated to have died of puerperal fe- 
ver, and 6 in child-bed-. 



259 



The folio A& is taken from an abstract of the 

Registry, kept at the Lying-in Hospital in Dublin, 
from the 8th December, 1757, to the 31st December, 
1814, or 57 years, during which period, 78,000 
women were delivered in the Institution: — 

Proportion of Males and Females born, about 10 males, 

to 9 females. 
Children dying in the Hospital, about 

1 to 16. 

Children still-born, about 1 to 18. 

Women having twins (and more) about 

1 to 57. 
— — — — — Women dying in child-bed, about 1 to 93. 
— — — — — Women having 3 and 4 children, about 

1 to 3545. 

wx vw v-w v-vfe 

Abstract from the Registry, kept at the Lying-in Ward 
of the Philadelphia Aims-House, from the year 
1797, to 1815 inclusive, or 19 years. — Ed. 

Proportion of Males to Females born, about 10 males to 
8 females. 

• Children dying in the ward, about 1 to 18, 

Children still-born, about 1 to 11. 
— — - — — Women having twins, about 1 to 52.* 
Women dying in child-bed, about 1 to 97. 



• A different average was stated in p. 140 of this Synopsis, but that 
was taken from the result of 5 years onbj t in which twin cases had rery 
r«re!«- occurred. 



APPENDIX 



BY THE EDITOR. 



APPENDIX, 

Explaining the Mechanism of Parturition, hi which 
the Vertex is the presenting- part. 



vwvwvww-*- 



As it appears to be of considerable importance that 
the young practitioner should have correct ideas of 
the mechanism of parturition, or the mode in which 
the head presents at, and progresses through, the 
pelv*i3, and as without this preparatory knowledge, it 
is impossible to apply the forceps properly, when 
their aid becomes necessary, except by mere chance; 
we shall attempt here briefly to explain this subject, 
referring for fuller information than would be con- 
sistent with the conciseness of this Synopsis, to the 
writings of Baudelocque, Gardien, and to the improv- 
ed edition of Burns, published by the editor of this 
work. 



264 

The presentation of the vertex or crown of the 
head, as has been already explained in the commence- 
ment of this work, is recognised by the presence of 
a round solid tumour, upon which several sutures 
and fontanelles are to be traced. 

But even when the vertex presents, the sutures 
and fontanelles do not always correspond to the 
same point; this then has induced practitioners of 
midwifery to distinguish the different positions of 
the vertex, according to the manner in which this 
part presents at the superior strait or brim of the 
pelvis, and which is ascertained by the relative situa- 
tion of the fontanelles, and the direction of the su- 
tures. 

Although it may be asserted that there is no point 
of the pelvis, to which the posterior fontanelle, which 
we should always take for our guide, may not cor- 
respond; yet we may nevertheless, with Baudelocque 
and Gardien, confine the number, for the purposes of 
practice, to six principal ones. Indeed a sufficiently 
accurate idea of natural parturition might be given 
by describing a lesser number of positions. But, to 
explain fully those cases where the intervention and 
aid of art is required, it becomes necessary to admit 
them. 



265 



For properly to apply the forceps, and advantage- 
ously to act with them, the accurate knowledge of 
these different relations of the fcetal head with the 
pelvis, as well as its progress through the different 
stages of the labour until delivered, is supposed to 
be well understood. 

Let us then for the moment consider the circum- 
ference of the brim or superior strait of the pelvis as 
divided into two segments or semi-circumferences, 
one anterior and the other posterior. In the three 
first positions the posterior fontanelle answers to one 
of what we may venture to term the cardinal points 
of the anterior semi-circumference. [These presen- 
tations being included under the terms Eutocia Si?n- 
pkxy p. 9, Dystocia Diuthia, p. 27, and Dystocia 
Anenergica, p. 49, of this Synopsis.] 

In the three last positions the same posterior fon- 
tanelle answers to one of the diametrically opposite 
points of the posterior semi-circumference of the 
pelvis. [These three are included under the term 
Dystocia Perversa of this work, vid. p. 54.] 

If we observe the direction that the head pursues 
in each of these positions, when it is expelled by the 
efforts of nature alone, we shall find that in each of 



266 



them it offers some peculiarities, which it is of im- 
portance to understand. The mechanism of these 
different species of labour ought to be studied with 
the greater attention by the young practitioner, as it 
is this knowledge which is to guide him in all his 
operations in those cases where malposition of the 
head occurs. [Refer to p. 54, et seq. of this Sy- 
nopsis.] 

EUTOCIA, 

Including thejirst, second^ and third Positions, 

FIRST POSITION. 

In this position, (at the commencement of labour) 
the posterior fontanelle answers to the left acetabu- 
lum. The back of the infant is situated towards the 
anterior and left lateral portion of the uterus and 
pelvis: the face and the breast answering to their 
posterior and right lateral portions. The feet and 
breech are towards the fundus uteri. 

At the commencement of labour it is frequently 
only the middle portion of the sagittal suture which 
presents at the centre of the superior strait; whilst 
both the fontanelles remain as yet, out of the reach of 
the finger in the common examination. We cannot. 



267 

therefore, at this period, accurately determine the 
precise position of the head. For although we may 
ascertain that the sagittal suture is directed from the 
left acetabulum to the right sacro-iliac symphysis, 
we are as yet ignorant whether the posterior fonta- 
nels is situated in the anterior or posterior segment 
of the pelvis, and of consequence, whether the ver- 
tex presents in the first or the fourth position. The 
same difficulty presents in discriminating between 
the second and the fifth position, and between the 
third and the sixth, whilst we can only reach the 
sagittal suture. 

In the first period of labour, it is commonly one of 
the parietal bones which presents. As the labour 
advances, the middle portion of the sagittal suture 
retires from the centre of the pelvis, to give place to 
one of the fontanelles; and it is the posterior fonta- 
nelle that most frequently presents. 

When the waters have been discharged, the first 
contractions of the uterus tend, in the natural pro- 
gress of labour, to bend the head upon the breast. 
Whilst this is taking place, the posterior fontanelle 
approaches nearer and nearer to the centre of the 
pelvis. The head thus bent, continues to progress 
through the cavity passing from before, backwards, 
2M 



268 



in order to accommodate itself to the axis of the su- 
perior strait; and thus it continues to descend, until 
checked by the sacrum, the coccix, and the peri- 
neum. 

Whilst the head descends into the cavity of the 
pelvis in a diagonal direction, one of the parietal 
protuberances passes before the left sacro-iliac sym- 
physis, and the other behind the right acetabulum. 

In this position it is the right parietal bone which 
answers to the arch of the pubis. One of the branches 
of the lambdoidal suture answers to the left branch 
of the pubis, and the other is directed towards the 
left ischiatic notch. This has often been mistaken 
for the sagittal suture: and in consequence of its di- 
rection, which is from before, backwards, it has been 
supposed that the head had already performed its 
movement of rotation, by which the posterior fonta- 
nelle is ultimately brought under the arch of the 
pubis. 

The head having arrived at the bottom of the pel- 
vis, can no longer follow its first direction, being 
checked by the sacrum and coccix. But the contrac- 
tions of the uterus continuing to act upon it, force 
the occiput, as it were, to revolve from behind, for- 



269 

wards upon the inclined plane which the left side of 
the pelvis offers, in order to advance towards the 
svmphysis of the pubis; whilst, at the same time, the 
face turns into the hollow of the sacrum, revolving, 
as it were, from before, backwards upon the inclined 
plane which the other side of the pelvis presents. If 
the fingers are placed upon the posterior fontanelle, 
whilst the head retains its lateral position, it may 
sometimes be perceived to perform this movement 
on its axis during a strong pain. 

Whilst the occiput approaches the arch of the pu- 
bis, the trunk remains stationary in the cavity of the 
uterus. 

This pivot-like motion of the occiput, depends 
solely upon the twisting of the neck: and this rota- 
tion being performed, the posterior fontanelle is situ- 
ated towards the centre of the arch of the pubis, and 
the anterior towards the sacrum. The sagittal suture 
is parallel to the great diameter of the inferior strait; 
the branches of the lambdoidal suture answering to 
each side of the pelvis. 

The chin, which, until this period, had remained 
constantly applied to the breast, now begins to recede 
from it. The occiput dilates the external parts, and 



270 



engages under the arch of the pubis, under which it 
revolves, in rising and approaching towards the ab- 
domen of the mother. Whilst the occiput thus pro- 
gresses, the nape of the neck, which may be consi- 
dered as the centre of motion, revolves under the 
inferior edge of the arch of the pubis. 

In this motion the occiput passes over but a small 
space, whilst the chin, in describing a curve, pro- 
gresses from the sacrum to the inferior commissure 
of the labia* 

The expulsive forces bear upon the forehead and 
upon the face during this period of labour, and 
oblige the chin to recede from the breast. The neck 
is sufficiently long to allow the head to be delivered 
without the trunk's advancing. If the head in its 
passage does not accommodate itself to the curved 
line above described, but descends directly in the 
axis of the superior strait, every effort bears upon the 
perinaeum, which is then in danger of rupturing in 
its centre. 

If we do not succeed in obliging the head to fol- 
low the direction above described by applying pres- 
sure from behind forwards, and from the perinaeum 
upwards, the only means to prevent the laceration of 



271 



this part, is to apply the forceps, in order to direct 
the head forward, and thus oblige the chin to recede 
from the breast. 

Scarcely is the head delivered, when the face turns 
towards the right thigh of the woman, to which it 
answered in the commencement of labour; for it 
only turns into the hollow of the sacrum, in conse- 
quence of the twisting of the neck, and resumes the 
first position as soon as the neck is restored to its 
former situation. 

When the head is completely delivered, the shoul- 
ders, which had entered the superior strait diago- 
nally, as well as the head, turn, one towards the pu- 
bis, and the other towards the sacrum. The left 
shoulder which is towards the sacrum, approaches 
the vulva, and begins to be engaged there, whilst 
the right shoulder remains applied behind the sym- 
physis of the pubis until the other appears externally; 
which indicates, that when it is proper to assist in 
extricating the shoulders, we should act principally 
upon that which is placed posteriorly. 

Such is the progress of nature in this species of 
parturition, as every one may convince himself, if he 
will trace it step by step through the course of the 



272 



labour. And in this observation he will be able to 
distinguish three different movements. In the first 
period, the head bends itself towards the breast, and 
progresses through the cavity of the pelvis. In the 
second, it performs a motion, which brings its long 
diameter in the direction of pubis and sacrum. In 
the third, the chin quits the breast, and the occiput 
turns backwards in disengaging itself from under 
the pubis. The head ought to present its greatest 
diameters to the greatest diameters of the straits; 
but as it regards the superior strait, it does not pre- 
sent, as is commonly supposed, its smallest diameter 
to the smallest of that strfit. Its smallest diameter 
is directed from one sacro-iliac symphysis, to the 
opposite acetabulum. The portion of the head which 
passes between the pubis and the sacrum, is still less 
than that which is termed its small diameter. 

This species of labour would always be the most 
advantageous, if the laws of nature were invariably 
carried into effect; but in proportion as nature varies 
from the line that has been delineated, the labour be- 
comes more and more difficult, and often indeed, 
impossible, without the aid of ark 



273 



SECOND POSITION. 

In this position the posterior fontanelle is placed 
behind the right acetabulum, and the anterior is situ- 
ated before the left sacro-iliac symphysis, so that the 
back of the child answers to the anterior and right 
lateral portions of the uterus and of the pelvis; whilst 
the face, the breast, and the knees, are situated to. 
wards their posterior and left lateral portions. 

The mechanism of labour in this position is per- 
fectly similar to that of the preceding. As in that, if 
the expulsive forces are directed in such a manner, 
as to apply the chin of the infant more and more to 
the breast, the occiput progresses during the first 
period through the depth of the cavity of the pelvis. 
In the second period, the occiput slides from behind 
forwards, upon the inclined plane, which is presented 
by the right side of the pelvis, in order to place itself 
under the arch of the pubis; whilst at the same time, 
the face turns into the hollow of the sacrum. In the 
third period, the expulsive forces oblige the chin to 
recede from the breast; the occiput dilates the vulva 
as it turns upwards towards the pubis. This move- 
ment of the occiput is but inconsiderable; it only 
makes a slight turn, whilst the nape of the neck re- 
volves under the superior part of the arch of the pu- 



274 



bis. In order that this flexion of the head backwards 
may take place, it is necessary that the face should 
pass over a curve, which in its course, extends along 
the whole length of the sacrum, to the anterior edge 
of the perinseum. 

As soon as the head is delivered, the face turns 
towards the left thigh, to which it primarily answer- 
ed; the left shoulder turns towards the pubis, and 
the right towards the sacrum. This latter alone ad- 
vances, until it appears at the vulva. 

The relative proportions of the diameters of the 
child, with those of the pelvis, are really the same in 
this position as in the former. The occiput and the 
face have not a larger space to traverse in the posi- 
tion where the posterior fontanelle is situated to- 
wards the right acetabulum, than in that where it is 
placed behind the left. Hence it would appear, that 
one of these positions ought to be as favourable as 
the other, to the expulsion of the child. But there 
are, notwithstanding, greater difficulties experienced 
in that where the occiput is to the right; because the 
rectum^ which is placed on the leftside of the sacrum, 
prevents the forehead from turning so readily into 
the hollow of that bone. 



275 



THIRD POSITION. 

In this position the posterior fontanelle is imme- 
diately behind the symphysis pubis, and the anterior 
before the projection of the sacrum. The back of the 
infant is towards the anterior, and its abdomen to- 
wards the posterior portion of the uterus. For a 
long time this was considered as the most common 
and the most advantageous position, but both of 
these suppositions are incorrect; for, experience on 
the contrary, proves, that it is very rare; so much so, 
indeed, that many practitioners who have never met 
with it, have absolutely called its existence in ques- 
tion.* Those who have imagined that the occiput 
constantly answered to the pelvis from the very com- 
mencement of labour, have only been induced to 
think so, from observing it disengage itself in this 
direction from the inferior strait. A regular exami- 
nation through the whole progress, would have taught 
them, that, although the occiput is expelled from 
under the pubis, it nevertheless enters the superior 
strait diagonally, as in the first or second position. 



* So rare is this position, that in 12,183 cases of presentations of the 
crown of the head, of which an accurate register was kept in l'Hospice 
tie la Maternite at Paris, it occurred but four times. Vide Bandelocqut 
Art des Acoouchemer.s. Vol. II. 

2N 



276 



But when the occiput at the commencement of 
labour, does present at the superior strait in the third 
position, the forehead, which is placed immediately 
before the upper part of the sacrum, will probably be 
turned towards one or other sacro-iliac symphysis by 
the projection of the sacrum, by which operation, 
the third position will be converted into the first or 
second. But as the rectum lies on the left side of the 
sacrum, and presents an obstacle to the forehead on 
that side, it will more readily be turned to the right 
sacro-iliac symphysis, the occiput at the same time 
approaching the left acetabulum, thus constituting 
the first position heretofore described. 

It is, nevertheless, a possible, although an ex- 
tremely rare case, for the occiput to pass through 
the superior strait directly behind the symphysis pu- 
bis. Here then, as the long diameter of the head is 
opposed to the small diameter of the strait, the diffi- 
culty which is experienced by the head in its passage 
must be greater. Nevertheless, if no obliquity ex- 
ists, parturition may ultimately be accomplished; be- 
cause, in a well formed pelvis, the short diameter of 
the strait is four inches, and the long diameter of the 
head is no greater. Besides, if the head engages 
favourably, it only presents its height, or its perpen- 
dicular diameter, because the chin rises towards the 



277 



breast of the infant, which facilitates the expulsion of 
the head. 

There are but two periods to be taken notice of 
in the progress of this species of labour: the face re- 
mains towards the perinaeum for some time after the 
delivery of the head; it does not turn to one or other 
of the thighs, until after the shoulders, which had 
entered the strait diagonally, have presented at the 
inferior strait, one being towards the pubis, and the 
other towards the sacrum; but they turn indifferently 
to one or the other side of the pelvis, because the 
head has not been obliged to perform the pivot-like 
motion. Of course, it is not in our power previously 
to designate which shoulder will turn towards the 
pubis. 



In the three next positions of the vertex that re- 
main to be explained, the posterior fontanelle an- 
swers to one of, what we have ventured to call, the 
cardinal points of the posterior semi-circumference 
of the pelvis, and which, in this Synopsis, are classed 
under the title of " Dystocia Perversa, or labour 
in which the head p'.estnts in a wrong direction," 
vide p. 54, et seq. 



278 



FOURTH POSITION. 

In this position, the anterior fontanelle is behind 
the left acetabulum, and the posterior before the 
right sacro-iliac symphysis, and the course of the* 
sagittal suture is obliquely, from the former to the 
latter point. The back of the infant is to the right 
posterior portion, and its breast, &c. towards the left 
anterior portion of the uterus. [This is what by Gar- 
dien is termed Position fronto-cotyloidienne gauche. 
Vide Synopsis, p. 55.] 

Although at the commencement of labour, the 
posterior fontanelle is placed towards the right sacro- 
iliac symphysis, the face does not always come out 
under the arch of the pubis. We sometimes observe, 
that the occiput approaches the right acetabulum, in 
proportion as the head advances in the pelvis. When 
the spontaneous conversion of the fourth to the 
second position takes place, it is to be considered as 
extremely favourable for the patient. From hence an 
inference has been drawn, that when the practitioner 
meets with this position, he ought, at the commence- 
ment of labour, to facilitate its progress, and lessen 
the suffering of the female, when the face is turned 
towards the symphysis of the pubis, by making an 
effort to disengage it from that part, and bring the 



279 



occiput, during the pains, rather forward towards the 
pubis, than towards the sacrum. If the membranes 
have not been ruptured, it is impossible to touch the 
head during the existence of a pain. This conversion 
cannot be accomplished without risk, except we act 
at the instant of the discharge of the waters. When 
nature spontaneously produces this conversion in the 
fourth and fifth position, the same change of relative 
situation takes place in the trunk. We ought not, 
therefore, to attempt producing it by art, unless the 
child is sufficiently moveable, to permit the trunk to 
undergo the same changes in situation as the occi- 
put; unless this were the case, the neck would suffer 
a twisting, which would amount to the third of a 
circle. It may be important to recollect the possibi- 
lity of this conversion, in those cases in which we 
are obliged to apply the forceps, because the mode of 
proceeding will be different if that has taken place. 
We should, therefore, before applying the forceps, 
endeavour to ascertain whether or no the face is to- 
wards the pubis. 

If the change of position, of which we have just 
spoken, has not taken place, the deliver}' of the head 
becomes more difficult, because, in the second pe- 
riod, the face turns towards the symphysis of the 
pubis. This part is disengaged with more diffi- 



280 



ficulty from under the arch of the pubis, than the 
occiput; for the arch has less breadth in its superior 
part, than the forehead and the face of the infant. 
The form of the occiput, on the contrary, accom- 
modates itself very well to the arch of the pubis, 
under which it turns, whilst the face disengages it- 
self behind. 

If in this position, the contractions of the uterus 
are directed in such a manner, as to bear upon the 
occiput, it descends into the pelvis, passing before 
the right sacro-iliac symphysis. When the head 
reaches the sacrum, it can no longer follow its first 
direction. The contractions of the uterus oblige it to 
perform a pivot-like motion, which turns the occiput 
into the hollow of the sacrum, descending along the 
inclined plane of the right side; whilst at the same 
time, the forehead places itself under the pubis, slid- 
ing along the inclined plane, which the left side of 
the pelvis offers. At the end of this second period, 
the anterior fontanelle is situated behind the pubis, 
and the posterior towards the sacrum. 

In the last period, the forehead cannot engage 
under the arch of the pubis, as the occiput does in 
the three preceding positions; it is obliged to ascend 
behind the symphysis, to the internal surface of 



281 



which it remains applied, whilst the posterior fon- 
tanelle passes over the length of the sacrum, the coc- 
cix and the perinaeum, to arrive -t the bottom of 
the vulva. At this moment, the edge of the peri- 
neum is considerably stretched, and runs a greater 
risk of laceration than in the preceding positions. 
The perinaeum not being capable of remaining sta- 
tionary upon the inclined plane which the occiput 
offers, retires suddenly towards the base of the neck 
of the infant. 

The posterior edge of the perinaeum becomes then 
the point of support, or axis, upon which the nape of 
the neck revolves, whilst the occiput turns backwards 
towards the anus of the woman: In proportion as the 
head turns backwards, upon the perinaeum, the face 
disengages from under the pubis. We observe suc- 
cessively appear, the forehead, the orbits, the nose, 
the mouth and the chin. As soon as the chin appears 
externally, the face turns towards the left thigh, to 
which it primarily answered. The left shoulder pre- 
sents afterwards, towards the pubis, and the right 
towards the sacrum. That which is posterior, disen- 
gages the first, the other remaining stationary. 



282 



FIFTH POSITION: 

(Or position fronto-cotyloidienne droite, vid. Synop, 
p. 55.) 

In this position, the anterior fontanelle is behind 
the right acetabulum, and the posterior before the 
left sacro-iliac symphysis. The back of the infant is 
towards the left and posterior part of the uterus; its 
breast and abdomen is towards the right and anterior 
part. It is not unfrequently the case, that the efforts 
of nature alone, are competent to convert this posi- 
tion into the first, the occiput gradually approaching 
towards the left acetabulum, in proportion as it de- 
scends into the pelvis. All the observations that 
have been made on the preceding position, with res- 
pect to attempting, by the aid of art, what nature 
herself sometimes performs, are equally applicable 
to this position. 

The relations of the dimensions of the head of the 
child with those of the pelvis, are absolutely the 
same in this position, as in the preceding; the face 
turns equally upwards. Hence the mechanism of 
this species of labour, is in every respect, similar to 
that of the preceding position. If every thing is in 



283 

the natural order, the occiput descends into the pel- 
vis, passing before the left sacro-iliac symphysis. In 
the second period it turns towards the sacrum, at 
the same time that the forehead turns towards the 
symphysis pubis. The presence of the rectum on the 
left side of the pelvis, renders this rotation more 
difficult, by preventing the occiput from turning 
freely into the hollow of the sacrum. This position 
is one of those, in which it is most essential to eva- 
cuate the rectum by an enema. 

As soon as the face is disengaged from under the 
pubis, it turns to the right groin. The right shoulder 
is afterwards directed towards the pubis, and the 
left towards the sacrum. The latter alone advances, 
until it appears at the vulva. 



SIXTH POSITION: 

(Or position fronto-pubienne) vid. Synop. p. 55.) 

In this position, the anterior fontanelle is behind 
the pubis. The sagittal suture is parallel to the small- 
est diameter of the superior strait. The occiput and 
the back of the infant is towards the sacrum. 
• o 



284 

This position is the least favourable of all those 
which the occiput can take. Not only does the head 
present its length to the smallest diameter of the su- 
perior strait, but also the face is anterior, as it re- 
gards the pelvis, as in the two preceding positions. 
Fortunately, it is the most rare of all.* The round- 
ed form of the head, with difficulty, permits it to re- 
main fixed during labour, against the projection of 
the sacrum, so that even supposing it should answer 
to this part of the sacrum at the commencement of 
the labour, it would soon turn to one of its sides, 
which would be better accommodated to its figure. 
When we happen to see the face disengage itself 
from under the pubis towards the end of labour, we 
are not thence to suppose, that the head engaged in 
that way in the superior strait. Although in the two 
preceding positions, the head traverses this strait in 
a diagonal situation, the face, which, in the first pe- 
riod, was placed towards one or other of the aceta- 
bula, turns by a pivot-like motion towards the arch 
of the pubis, from under which it is delivered. 



* So extremely rare is this position, that of 12,183 cases, in which 
the vertex presented at I'Hospice de la Maternite at Paris, and of which 
an accurate register was kept, this position occurred but once. VicL 
Baudelocque Art des Accouchemens, vol. ii. 



285 

We can distinguish but two periods in this posi- 
tion. If the expulsive forces of the uterus act upon 
the occiput, as occurs in the natural order, it pro- 
gresses through the pelvis before the sacrum. Whilst 
the forehead is applied against the internal surface 
of the symphysis of the pubis, the occiput which 
ought to be delivered first, considerably distends the 
perinseum, passing over a curve line which extends 
from the hollow of the sacrum, to the lower edge of 
the vulva. At this instant the perinseum retires 
backwards, and passes under the nape of the neck, 
which revolves above it, whilst the occiput turns 
backwards towards the anus of the woman. As soon 
as the occiput begins to turn backwards, the different 
parts of the face, which until then had been retained 
in the interior of the pelvis, successively disengage 
themselves from under the pubis, in the order which 
has already been pointed out. 

When the chin appears externally, the face re- 
mains some time stationary: afterwards it turns to- 
wards one of the woman's groins, but only at the 
same instant that one of the shoulders presents to- 
wards the pubis, and the other towards the sacrum. 
This position also, is one of those, in which it is un- 
certain, which of the shoulders may present towards 
the pubis; and whes the change of position is pro- 



286 

cured by the aid of art, it is indifferent which we 
bring there. 

These divisions of the presentations of the vertex, 
or crown of the head, originated, as we believe, with 
the experienced Baudelocque — and on this subject, 
he very judiciously observes, that the head may, 
without doubt, present at the superior strait, in a 
manner different from those described. The poste- 
rior fontanelle, which, as we have before observed, 
we should always take for our guide, may sometimes 
correspond to the intermediate spaces between those 
six points; so that we might, perhaps, distinguish six 
other positions, which might be again subdivided 
into as many more. This distinction, he remarks, 
would not only be useless and superfluous, but might 
confuse the ideas. There is not, in fact, any of these 
middle positions, which may not be referred to one 
of the six first; and each of them ought therefore 
properly, to be designated by the name of that to 
which it approaches the nearest, as the mechanism 
of delivery in it is exactly the same. 

These intermediate positions therefore, ought to 
be referred to the three first, as often as the poste- 
rior fontanelle answers to any point of the anterior 
semi-circumference of the pelvis; because that fonta- 



287 

nclle turns gradually towards the symphysis of the 
pubis, under which the occiput is ultimately situated. 

The head, continues Baudelocque, sometimes fol- 
lows this direction, even though the fontanelle in 
question, be placed opposite one of the sacro-iliac 
symphyses at the commencement of labour: but, 
when it is more backward, and answers to some 
point in the posterior third of the superior strait, 
all those positions ought to be referred to the three 
latter, that is to say, to the fourth, fifth, or sixth; be- 
cause the occiput constantly turns in descending, 
towards the sacrum, and the forehead under the 
pubes. 




EXPLANATION OF THE PLATES. 



wvwwvwvw 



EXPLANATION OF PLATE I. 

This figure presents a well formed pelvis, whose 
parts are all reduced to about half their natural size. 

A, A, A, A, The ossa ilia, properly so called. 

a, a, The iliac fossae. 

b, b, b, b, The angle which divides transversely, 
and obliquely from behind forward, the internal sur- 
face of the os ilium into two parts, and which makes 
part of the brim of the pelvis, called linea ileo- 
pectinea. 

c, c, c, c, The crista of the ossa ilia. 

e, e, The anterior superior spines of the ossa ilia. 

f, f, The angle formed by the internal lip of the 
crista of the ilium, and to which is attached a liga- 
ment inserted at the other end in the transverse 
apophysis of the last lumbar vertebra. 

g, g, The inferior angle of the os ilium which 
makes part of the acetabulum. 

B, B, The os ischium. 



290 



h, h, The tuberosities of the os ischium. 
i, i, The branches of the os ischium. 
k, k, The posterior part of the os ischium, which 
makes part of the acetabulum. 

C, C, The body of the os pubis. 

1. 1, The angle of the os pubis. 

m, m, The posterior extremity of the os pubis, 
which makes part of the acetabulum. 

n, n j The descending branch of the os pubis, which 
unites with that of the ischium. 

D, D, D, The os sacrum. 

1.2, 3, 4, The anterior sacral holes, 
o, o, o, The base of the sacrum. 
p, p, The sides of the sacrum. 

• q, The point of the sacrum. 

E, The coccyx. 

F, The last lumbar vertebra. 

r, r, The transverse apophyses of that vertebra, 
s, s,The ligament which goes from the transverse 
apophysis of the last vertebra to the angle of the in- 
ternal lip of the crista of the os ilium, indicated by 
the letters f, f. 

t, t, Another ligament which descends from those 
same apophyses to the superior edge of the sacro-iliac 
symphyses. 

G, G, The femur t or thigh bone. 




291 



V, V, The head of the femur received in the aceta* 
bulum. 

u, u, The foramina ovalia. 



Symphyses of the Bones of the Pelvis. 



H, The symphyses of the ossa pubis. 
I, I, The sacro-iliac symphyses. 
K, The sacro-vertebral symphysis. 



2F 



292 



EXPLANATION OF PLATE II. 

This figure represents the entrance or superior 
strait of a well-formed pelvis, reduced to the half of 
its natural dimensions. 

a, a, The iliac fosses, 

b, The sacro-vertebral angle, or the projection of 
the sacrum, 

c, The last lumbar vertebra, 

d, d, The lateral parts of the base of the sacrum, 

e, e, The sacro-iliac symphyses. 

f, f, The parts over the acetabula, 

g, The symphysis of the pubes. 

The lines indicate the different diameters of the 
superior strait, 

A, B, The antero-posterior or little diameter. 

C, D, The transverse or great diameter. 

E, F, Oblique diameter, which extends from the 
left acetabulum to the right sacro-iliac junction. 

G, H, Oblique diameter, which goes from the 
right acetabulum to the left sacro-iliac symphysis. 
The oblique diameters may be considered as the 
greatest in the living subject; and it is in this direc- 
tion that the long diameter of the fcetal head gene- 
rally descends. 



293 



EXPLANATION OF PLATE III. 

This figure represents the inferior strait of a 
well-formed pelvis, reduced to the half of its natural 
size. 

a, a, The external surfaces of the ossa ilia. 

b, b, The anterior superior spines of the ossa ilia. 

c, c, The anterior inferior spines of the ossa ilia. 

d, d, The acetabula. 

e, e, The foramina ovalia with the obturator liga- 
ments. 

f, f, The ischiatic tuberosities. 

g, g, The ossa pubis. 

h, h, The branches of the os pubis and ischium 
united. 

i, i, The sacrum. 

k, The coccyx. 

1, 1, The sacro-ischiatic ligaments. 

m, The symphysis of the pubes. 

n, n, The arch of the pubes. 

The lines indicate the diameters of the inferior 
strait. 

A, A, The anteroposterior or great diameter. 

B, B, The transverse or little diameter. 
C C, D D, Oblique diameters. 




294 



EXPLANATION OF PLATE IV. 

This figure represents a deformed pelvis, of which 
all the parts are reduced to half their natural size. 

a, a, The ossa ilia. 

b, b, The ossa pubis. 

c, c, The ossa ischia. 

d, d, d, The last lumbar vertebra. 

e, The projection of the sacrum. 

f, f, The sacro-iliac symphyses. 

g, The symphysis of the pubes. 
h, h, The foramina ovalia. 
i, i, The branches of the ossa pubis and ischia, 

which form the anterior arch of the pelvis. 

k, k, The ace tabula. 

The lines indicate the diameters of the superior 
strait of this pelvis. 

A, A, The antero-posterior diameter; its natural 
length is fourteen or fifteen lines.* In Elizabeth 
Sherwood's case, Dr. Osborne states, that this dia- 
meter did not exceed 3-4ths of an inch. Vid. Os- 
borne's Essays, p. 1 89. The child in this case, was 
delivered by embryulcia and the crochet: the wo- 



* A line is the 12th part of an inch, as has heretofore been explained. 




t— ' 

I 



295 



man recovered. In Mary Rhodes's case, this diame- 
ter measured only 7-8thsof an inch. Here the Cesa- 
rian section was performed — she expired five hours 
afterwards. Vide Lond. Med. Observations and 
Enquiries, vol. iv. A. D. 1771. 

B, B, The transverse diameter; its natural length 
is four inches ten lines. 

C, C, The distance from the projection of the 
sacrum, to that point of the margin which answers to 
the left acetabulum, thirteen lines. 

D, D, The distance from the same point of the 
sacrum, to that of the margin which answers to the 
right acetabulum, twenty lines. 

Baudelocque, from whose work these plates are 
taken, observes, that he has another pelvis, which has 
an opening of between three and four lines only in 
the direction of this last line, and an inch and an half 
from the middle of the projection of the sacrum to 
the symphysis of the pubes. 

The inferior strait in both these pelves is very 
large. 



295 



EXPLANATION OF PLATE V. 

This figure represents a deformed pelvis, in which 
the parts are reduced to half their natural size. 

a, a, The ossa ilia. 

b, b, The ossa pubis. 

c, c, The ossa ischia. 

d, d, d, The last lumbar vertebras. 

e, The projection of the sacrum. 

f, f, The sacroiliac symphyses. 

g, The symphysis of the pubes. 

h, h, The foramina ovalia, seen obliquely. 

i, i, The arch of the pubes, seen in the same man- 
ner. 

k, k, The acetabula. 

The lines indicate the different dimensions of the 
superior strait. 

A, A, From the pubes to the projection of the 
sacrum, in the natural state of iKispehis, two inches 
two lines. 

B, B, The transverse diameter, three inches eight 
lines. 

C, C, From the middle and left side of the projec- 
tion of the sacrum, to that part of the margin which 
answers to the acetabulum of the same side, between 
six and seven lines. 




3 

Fd 



297 



D, D, From the middle and right side of the pro- 
iection of the sacrum, to that part of the margin 
which answers to the right acetabulum, one inch two 
lines. 

This pelvis was taken from the cabinet of M. RieU 
The subject was a woman of twenty-seven years. 



THE END. 









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